Telehealth Consent & HIPPA Privacy Notice
docs.google.com/document/d/1MHXMuUBEc2WTxFQtigG9TdPx3tamAFmL_mtdvftgezo/edit?usp=sharing Dr. Corinne Menn, D.O, PLLC
Telehealth Informed Consent & Practice Policies
I understand and agree with the following:
Telehealth Informed Consent
1. Telehealth is the delivery of health care services using video or audio technologies between a provider and a patient who are not in the same physical location. Dr. Corinne Menn, D.O, PLLC is entirely a telehealth practice offering women’s health consultations. Dr. Menn is licensed in the state in which I am receiving telehealth services . The laws of the state in which I am located will apply to my receipt of telehealth services.
2. I understand the risks and benefits of engaging in telehealth. I may discuss these risks and benefits with Dr. Menn and will be given an opportunity to ask questions about telehealth services. I have the right to withdraw this consent to telehealth services or end the telehealth session at any time without affecting my right to future treatment by Dr. Menn.
3. I further understand that any medical advice, recommendations, and/or decisions may be based on factors not within Dr. Menn’s control, including incomplete or inaccurate data provided by me. I understand that Dr. Menn relies on information provided by me before and during our telehealth encounter and that I must provide information about my medical history, condition(s), and current or previous medical care that is complete and accurate to the best of my ability. If that information changes while under the care of Dr. Menn, I will update her.
4. Electronic systems used will incorporate network and software security protocols to protect the privacy and security of health information and imaging data, and will include measures to safeguard the data to ensure its integrity against intentional or unintentional corruption. Dr. Menn is utilizing a HIPAA-compliant license for Zoom in order to minimize these risks to the best of their ability. Please see here for details on Zoom for Telehealth https://explore.zoom.us/docs/doc/Zoom-hipaa.pdf
5. In the event of disruption of service, or for routine or administrative reasons, it may be necessary to communicate by other means. If the video technology is not working, Dr. Menn will call you on the telephone number that you have provided when registered as a patient.
6. Dr. Menn and I will regularly reassess the appropriateness of continuing to deliver services to me through the use of telehealth and modify our plan as needed. If Dr. Menn or I believe I would be better served by in person services or another form of care, I will be referred to a medical provider, hospital ,emergency department or other appropriate health care provider. In case of an emergency, I will dial 911 or go directly to the nearest hospital emergency room.
7. Dr. Menn may utilize alternative means of communication as follows:
She may send me a secure message through the Practice Fusion Patient Portal. Messaging is encouraged via the portal, because it is secure and HIPPA-compliant and the messages stay as part of your medical record. If you have questions or need to contact Dr. Menn , please use the patient portal primarily. The practice phone number is 914-238-0350 and patients can call there or text or email Dr. Menn at drmenn@drmenn.com I understand that email and standard SMS messaging are not confidential methods of communication and may be insecure. I further understand that, because of this, that email and standard SMS messaging regarding my medical care might be intercepted and read by a third party. Please note that all textual messages you exchange with your provider, e.g. emails and text messages, may not be a secure method of communication and will become a part of your health record.
8. I have the right to review and receive copies of my telehealth medical records, including all information obtained during a telehealth interaction, subject to Dr. Menn’s standard policies regarding request and receipt of medical records and applicable law.
9.It is my responsibility to maintain privacy on the patient end of communication. Dr. Menn follows security best practices and legal standards in order to protect your health care information, but you will also need to participate in maintaining your own security and privacy.
10. Documentation (i.e. chart notes) will be stored on the private server of the Practice Fusion electronic medical records software. Please do not record video or audio sessions without Dr. Menn’s consent. Making recordings can quickly and easily compromise your privacy and should be done so with great care. Dr. Menn will not record video or audio sessions.
Practice Policies
Appointment Confirmations
Three appointment reminders are sent to patients prior to an appointment: 1-week prior (via email), 36-hours prior (via email), and 24-hours prior (via voice or text message).
Appointment Cancellations
We ask that all cancellations be made at least twenty-four hours in advance of the scheduled appointment. You can cancel on the portal, call or text the office or send an email.
Cancellations prior to 24 hours from the appointment time will be refunded in full.
Cancellations less than 24 hours in advance of the scheduled appointment time will not be refunded, but will be credited towards a future appointment.
No Show Fee If you do not show up for the telehealth appointment and did not notify the office that you are cancelling, there will be no refund and no credit issued .
Payments Payments at the time of booking. Patients will receive a Square invoice to be paid once the appointment is booked.
Insurance Dr. Menn does not participate in any commercial insurance plans or Medicare and we do not file any insurance claims on behalf of patients.
Once you have had your vist, you can download an itemized and properly coded receipt. It can be used to submit to insurance if you have out of network benefits, to apply to a deductible or reimbursement from an HSA account.
Patient Portal Please utilize the secure patient portal for ALL electronic messages. Regular email is not secure in terms of patient privacy. Any non-urgent requests or questions, review of lab work andtests, co-pay payments, rx renewals, appointment requests,medical records requests can all be made via the portal. If you do not have access, please email the office at drmenn@drmenn.com
HIPPA Privacy Notice can be viewed and downloaded here
Release of Medical Records
In order to obtain a copy of your medical record, you must complete the form Authorization for Release of Health Information. You may use this one https://www.nycourts.gov/forms/hipaa_fillable.pdf or at www.drmenn.com There is not a fee for your medical records to be faxed to another healthcare provider. At anytime you can access your complete chart on the patient portal and download a copy for your own records.
By reading this consent and writing in your name below you agree to the information contained herein.
If you would like a copy of this, you can download the consent here .
Telehealth Informed Consent & Practice Policies
I understand and agree with the following:
Telehealth Informed Consent
1. Telehealth is the delivery of health care services using video or audio technologies between a provider and a patient who are not in the same physical location. Dr. Corinne Menn, D.O, PLLC is entirely a telehealth practice offering women’s health consultations. Dr. Menn is licensed in the state in which I am receiving telehealth services . The laws of the state in which I am located will apply to my receipt of telehealth services.
2. I understand the risks and benefits of engaging in telehealth. I may discuss these risks and benefits with Dr. Menn and will be given an opportunity to ask questions about telehealth services. I have the right to withdraw this consent to telehealth services or end the telehealth session at any time without affecting my right to future treatment by Dr. Menn.
3. I further understand that any medical advice, recommendations, and/or decisions may be based on factors not within Dr. Menn’s control, including incomplete or inaccurate data provided by me. I understand that Dr. Menn relies on information provided by me before and during our telehealth encounter and that I must provide information about my medical history, condition(s), and current or previous medical care that is complete and accurate to the best of my ability. If that information changes while under the care of Dr. Menn, I will update her.
4. Electronic systems used will incorporate network and software security protocols to protect the privacy and security of health information and imaging data, and will include measures to safeguard the data to ensure its integrity against intentional or unintentional corruption. Dr. Menn is utilizing a HIPAA-compliant license for Zoom in order to minimize these risks to the best of their ability. Please see here for details on Zoom for Telehealth https://explore.zoom.us/docs/doc/Zoom-hipaa.pdf
5. In the event of disruption of service, or for routine or administrative reasons, it may be necessary to communicate by other means. If the video technology is not working, Dr. Menn will call you on the telephone number that you have provided when registered as a patient.
6. Dr. Menn and I will regularly reassess the appropriateness of continuing to deliver services to me through the use of telehealth and modify our plan as needed. If Dr. Menn or I believe I would be better served by in person services or another form of care, I will be referred to a medical provider, hospital ,emergency department or other appropriate health care provider. In case of an emergency, I will dial 911 or go directly to the nearest hospital emergency room.
7. Dr. Menn may utilize alternative means of communication as follows:
She may send me a secure message through the Practice Fusion Patient Portal. Messaging is encouraged via the portal, because it is secure and HIPPA-compliant and the messages stay as part of your medical record. If you have questions or need to contact Dr. Menn , please use the patient portal primarily. The practice phone number is 914-238-0350 and patients can call there or text or email Dr. Menn at drmenn@drmenn.com I understand that email and standard SMS messaging are not confidential methods of communication and may be insecure. I further understand that, because of this, that email and standard SMS messaging regarding my medical care might be intercepted and read by a third party. Please note that all textual messages you exchange with your provider, e.g. emails and text messages, may not be a secure method of communication and will become a part of your health record.
8. I have the right to review and receive copies of my telehealth medical records, including all information obtained during a telehealth interaction, subject to Dr. Menn’s standard policies regarding request and receipt of medical records and applicable law.
9.It is my responsibility to maintain privacy on the patient end of communication. Dr. Menn follows security best practices and legal standards in order to protect your health care information, but you will also need to participate in maintaining your own security and privacy.
10. Documentation (i.e. chart notes) will be stored on the private server of the Practice Fusion electronic medical records software. Please do not record video or audio sessions without Dr. Menn’s consent. Making recordings can quickly and easily compromise your privacy and should be done so with great care. Dr. Menn will not record video or audio sessions.
Practice Policies
Appointment Confirmations
Three appointment reminders are sent to patients prior to an appointment: 1-week prior (via email), 36-hours prior (via email), and 24-hours prior (via voice or text message).
Appointment Cancellations
We ask that all cancellations be made at least twenty-four hours in advance of the scheduled appointment. You can cancel on the portal, call or text the office or send an email.
Cancellations prior to 24 hours from the appointment time will be refunded in full.
Cancellations less than 24 hours in advance of the scheduled appointment time will not be refunded, but will be credited towards a future appointment.
No Show Fee If you do not show up for the telehealth appointment and did not notify the office that you are cancelling, there will be no refund and no credit issued .
Payments Payments at the time of booking. Patients will receive a Square invoice to be paid once the appointment is booked.
Insurance Dr. Menn does not participate in any commercial insurance plans or Medicare and we do not file any insurance claims on behalf of patients.
Once you have had your vist, you can download an itemized and properly coded receipt. It can be used to submit to insurance if you have out of network benefits, to apply to a deductible or reimbursement from an HSA account.
Patient Portal Please utilize the secure patient portal for ALL electronic messages. Regular email is not secure in terms of patient privacy. Any non-urgent requests or questions, review of lab work andtests, co-pay payments, rx renewals, appointment requests,medical records requests can all be made via the portal. If you do not have access, please email the office at drmenn@drmenn.com
HIPPA Privacy Notice can be viewed and downloaded here
Release of Medical Records
In order to obtain a copy of your medical record, you must complete the form Authorization for Release of Health Information. You may use this one https://www.nycourts.gov/forms/hipaa_fillable.pdf or at www.drmenn.com There is not a fee for your medical records to be faxed to another healthcare provider. At anytime you can access your complete chart on the patient portal and download a copy for your own records.
By reading this consent and writing in your name below you agree to the information contained herein.
If you would like a copy of this, you can download the consent here .