SSV Holdings

Agreement for Self-Payment of Services + Informed Consent

Summa Up, LLC and its affiliated entities (collectively defined as “SummaUp”) is committed to providing the best quality healthcare services. We do not participate in any insurance plans, including Medicare or Medicaid, and we do not accept any health insurance whatsoever. Our services are 100% self-pay by our patients. By signing this form, you acknowledge that: 1) you do not have any health insurance through a PPO, HMO, Medicaid or Medicare or any other insurance plan; or 2) you have health insurance but you do not want to use any insurance benefit for these services, acknowledging that SummaUp does not accept any health insurance. 

Your insurance policy is a contract between you and your insurance company. It is your responsibility to know your benefits, and how they will apply to your benefit payments, and we take no responsibility to understand or be bound by the terms and conditions of such insurance. By signing this form, you are electing to purchase services that may or may not be covered by your insurance if you obtained those services from a different provider. You have selected services for purchase from us on a selfpay basis. In other words, you have directed us to treat your purchase of these services as if you are an uninsured patient and you agree to be 100% responsible for full payment of the listed price of the services. There is no guarantee your insurance company will make any payment on the cost of the services you have purchased. 

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SummaUp has provided you with the charges, in advance, for the services you have requested. By signing, you agree to pay these charges in full as a self-pay patient, electing not to use an insurance policy benefit. You have been given a choice of different services, along with their costs. You have selected the services and are willing to accept full financial responsibility for payment. 

I have read the Agreement for Self-Payment of Services. I understand and agree to this Agreement.

Informed Consent for Telehealth Services

Last Updated on June 20, 2019

YOU UNDERSTAND THAT BY CHECKING THE “AGREE” BOX FOR THESE TERMS OF USE AND/OR ANY OTHER SUCH FORM OF THE SAME PRESENTED TO YOU FROM TIME TO TIME ON THE SITE YOU ARE AGREEING TO THESE TERMS OF USE AND THAT SUCH ON-GOING ACTIONS IN USING THE SITE CONSTITUTE A LEGAL SIGNATURE AND ON-GOING AGREEMENT TO THESE TERMS OF USE (IN WHATEVER FORM).

All capitalized terms used in this Informed Consent to Telehealth Services but not defined herein have the meanings assigned to them in the Terms of Use. For avoidance of any doubt, the terms “Summa“, “we“, “us“, or “our” refer toSumma Up, LLC and the terms “you” and “yours” refer to the person using the Service.

Telehealth involves the use of electronic communications to enable healthcare providers at different locations to share individual patient medical information for the purpose of improving patient care. Telehealth services offered by Summa Up, LLC. and the members of its Affiliated Covered Entity (collectively “Group”) may also include chart review, remote prescribing, appointment scheduling, health information sharing, and non-clinical services, such as patient education. The information you provide may be used for diagnosis, therapy, follow-up and/or patient education, and may include any combination of the following: (1) health records and test results; (2) images and asynchronous communications; (3) live two-way audio and video; (4) interactive audio with store and forward; and (5) output data from medical devices and sound and video files.

The electronic communication systems we use will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

Group physicians (our “providers”) are an addition to, and not a replacement for, your primary care physician. Responsibility for your overall medical care should remain with your local primary care doctor, if you have one, and we strongly encourage you to locate one if you do not.

Expected Benefits:

• Improved access to care by enabling you to remain in your home while the Group provider consults and obtains test results at distant/other sites.

• More efficient care evaluation and management at times that are convenient for you

• You can interact with providers without the necessity of an in-office appointment

• Obtaining expertise of a specialist as appropriate.

Possible Risks:

• Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment and technologies.

• Information transmitted to your provider(s) may not be sufficient to allow for appropriate medical decision making by the provider(s).

• The inability of your provider(s) to conduct certain tests or assess vital signs in-person may in some cases prevent the provider(s) from providing a diagnosis or treatment or from identifying the need for emergency medical care or treatment for you.

• In rare events, our provider may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled telehealth consult or a meeting with your local primary care doctor.

• Your provider may not able to provide medical treatment for your particular condition via telemedicine and you may be required to seek alternative care.

• In very rare events, security protocols could fail, causing a breach of privacy of personal medical information.

• In rare events, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors.

If you need to receive follow-up care, assistance in the event of an adverse reaction to the treatment, or in the event of an inability to communicate as a result of a technological or equipment failure, please contact us at support@summaup.com or call us at 415-891-1090.

By clicking the button titled "I Agree and Consent", you acknowledge that you understand and agree with the following:

1. I hereby consent to receiving Group’s services via telehealth technologies. I understand that Group and its providers offer telehealth-based medical services, but that these services do not replace the relationship between me and my primary care doctor. I also understand it is up to the Group provider to determine whether or not my specific clinical needs are appropriate for a telehealth encounter.

2. I understand that federal and state law requires health care providers to protect the privacy and the security of health information. I understand that Group will take steps to make sure that my health information is not seen by anyone who should not see it. I understand that telehealth may involve electronic communication of my personal medical information to other health practitioners who may be located in other areas, including out of state.

3. I understand there is a risk of technical failures during the telehealth encounter beyond the control of Group. I agree to hold harmless Group for delays in evaluation or for information lost due to such technical failures.

4. I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment. I understand that I may suspend or terminate use of the telehealth services at any time for any reason or for no reason. I understand that if I am experiencing a medical emergency, that I will be directed to dial 9-1-1 immediately and that the Group providers are not able to connect me directly to any local emergency services.

5. I understand that alternatives to telehealth consultation, such as in-person services are available to me, and in choosing to participate in a telehealth consultation, I understand that some parts of the services involving tests may be conducted by individuals at my location, or at a testing facility, at the direction of the Group provider (e.g. labs or bloodwork).

6. I understand that I may expect the anticipated benefits from the use of telehealth in my care, but that no results can be guaranteed or assured.

7. I understand that while the use of telemedicine may provide potential benefits to me, as with any medical care service no such benefits or specific results can be guaranteed. My condition may not be cured or improved, and in some cases, may get worse.

8. I understand that “Providers” may determine in his or her sole discretion that my condition is not suitable for treatment using telemedicine, and that I may need to seek medical care and treatment in-person or from an alternative source.

9. I understand that the same confidentiality and privacy protections that apply to my other health care services also apply to these telemedicine services.

10. I understand that I have access to all of my health and wellness information pertaining to the telemedicine services in accordance with applicable laws and regulations.

11. I understand that I can withhold or withdraw this consent at any time by emailing Summa with such instruction. Otherwise, this consent will be considered renewed upon each new telemedicine consultation with “Providers”.

12. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Persons may be present during the consultation other than the Group provider in order to operate the telehealth technologies. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/examination that are personally sensitive to me; (2) ask non-medical personnel to leave the telehealth examination; and/or (3) terminate the consultation at any time.

13. I understand that I will not be prescribed any narcotics for pain, nor is there any guarantee that I will be given a prescription at all.

14. I agree and authorize my health care provider to share information regarding the  telemedicine exam with other individuals for treatment, payment and health care operations purposes.

15. I agree and authorize my health care provider to release information regarding the telemedicine exam to Summa and its affiliates.

16. I understand that if I participate in a consultation, that I have the right to request a copy of my medical records which will be provided to me at reasonable cost of preparation, shipping and delivery.

Additional State-Specific Consents: The following consents apply to users accessing the Group website, and only to the extent that the Group website is available to users in such states (the state specific language below does not imply the Group website is available is available in such state), for the purposes of participating in a telehealth consultation as required by the states listed below:

Alaska: I understand my primary care provider may obtain a copy of my records of my telehealth encounter. (AK Stat. 08.64.364).

Arizona: I understand I am entitled to all existing confidentiality protections pursuant to A.R.S. § 12-2292. I also understand all medical reports resulting from the telemedicine consultation are part of my medical record as defined in A.R.S. § 12-2291. I also understand dissemination of any images or information identifiable to me for research or educational purposes shall not occur without my consent, unless authorized by state or federal law. (A.R.S. § 36-3602).

Connecticut: I understand that my primary care provider may obtain a copy of my records of my telehealth encounter. (C.G.S.A. § 19a-906).

Washington D.C.: I have been informed of alternate forms of communication between me and a physician for urgent matters. (17 DCMR § 4618.10).

Kentucky: If I am a Medicaid recipient, I recognize I have the option to refuse the telehealth consultation at any time without affecting the right to future care or treatment and without risking the loss or withdrawal of a Medicaid benefit to which I am entitled. I understand that I have the right to be informed of any party who will be present at the site during the telehealth consult and I have the right to exclude anyone from being present. I also understand that I have the right to object to the videotaping of the telehealth consultation. (KY Admin. Regs. Tit. 907, 3:170).

Louisiana: I understand the role of other health care providers that may be present during the consultation other than the Group provider. (46 La. Admin. Code Pt XLV, § 7511).

Maryland: Regarding audiologists, speech language pathologists, and hearing aid dispensers, I recognize the inability to have direct, physical contact with the patient is a primary difference between telehealth and direct in-person service delivery. The knowledge, experiences, and qualifications of the consultant providing data and information to the provider of the telehealth services need not be completely known to and understood by the provider. The quality of transmitted data may affect the quality of services provided by the provider. Changes in the environment and test conditions could be impossible to make during delivery of telehealth services. Telehealth services may not be provided by correspondence only. (Code of MD Reg. 10.41.06.04).

Nebraska: If I am a Medicaid recipient, I retain the option to refuse the telehealth consultation at any time without affecting my right to future care or treatment and without risking the loss or withdrawal of any program benefits to which the patient would otherwise be entitled. All existing confidentiality protections shall apply to the telehealth consultation. I shall have access to all medical information resulting from the telehealth consultation as provided by law for access to my medical records. Dissemination of any patient identifiable images or information from the telehealth consultation to researchers or other entities shall not occur without my written consent. I understand that I have the right to request an in-person consult immediately after the telehealth consult and I will be informed if such consult is not available. (NE Revised Stat. 71-8505; NE Admin. Code Tit. 471, Ch. 1).

New Hampshire: I understand that the Group provider may forward my medical records to my primary care or treating provider. (N.H. Rev. Stat. § 329:1-d).

New Jersey: I understand I have the right to request a copy of my medical information and I understand my medical information may be forwarded directly to my primary care provider or health care provider of record, or upon my request, to other health care providers. (NJ Rev. Stat. § 45:1-62).

Pennsylvania: I understand that I may be asked to confirm my consent to behavioral health or tele-psych services.

Rhode Island: If I use e-mail or text-based technology to communicate with my Group provider, then I understand the types of transmissions that will be permitted and the circumstances when alternate forms of communication or office visits should be utilized. I have also discussed security measures, such as encryption of data, password protected screen savers and data files, or utilization of other reliable authentication techniques, as well as potential risks to privacy. I acknowledge that my failure to comply with this agreement may result in the Group provider terminating the e-mail relationship. (Rhode Island Medical Board Guidelines).

South Carolina: I understand my medical records may be distributed in accordance with applicable law and regulation to other treating health care practitioners. (S.C. Code 1976 § 40-47-37). Tennessee: I understand that I may request an in-person assessment before receiving a telehealth assessment if I am a Medicaid recipient.

Texas: I understand that my medical records may be sent to my primary care physician. (V.T.C.A., Occupations Code § 111.005).

Vermont: I understand that I have the right to receive a consult with a distant-site provider and will receive one upon request immediately or within a reasonable time after the results of the initial consult. I understand that receiving tele-dermatology or tele-ophthalmology services via Group does not preclude me from receiving real-time telemedicine or face-to-face services with the distant provider at a future date. (VT Stat. Ann. § 9361).

Emergency Situations

If there is an emergency situation telemedicine is not an appropriate method of care.

IN CASE OF AN EMERGENCY, YOU SHOULD SEEK IMMEDIATE MEDICAL ATTENTION OR EMERGENCY CARE BY CALLING 911.

Indemnification

YOU AGREE TO INDEMNIFY AND HOLD HARMLESS THE PROVIDER, ITS EMPLOYEES, AGENTS, DIRECTORS, MEMBERS, MANAGERS, SHAREHOLDERS, OFFICERS, REPRESENTATIVES, ASSIGNS, PARENTS, PREDECESSORS, AND SUCCESSORS FROM AND AGAINST ANY AND ALL LOSS OR DAMAGE, INCLUDING ANY AND ALL INDIRECT, INCIDENTAL, SPECIAL, CONSEQUENTIAL OR EXEMPLARY DAMAGES, EXPENSES, LIABILITIES, CLAIMS, OR DEMANDS WHATSOEVER ARISING OUT OF OR RELATED TO ANY FAILURE OF TECHNOLOGY OR EQUIPMENT IN CONNECTION WITH THE PROVISION OF TELEMEDICINE, WHETHER OR NOT ANY SUCH LOSS, DAMAGE, EXPENSE, LIABILITY, CLAIM, OR DEMAND ARISES FROM OR RELATES TO THE PROVIDER'S NEGLIGENCE.