Patient Consent to the Use and Disclosure of Information
Washington Nephrology Associates, L.L.P. (“WNA”) obtains and maintains health information relating to my past, present or future physical or mental condition, and provision of health care or payment for health care, referred to as “Protected Health Information.” This Protected Health Information may be used or disclosed by WNA for purposes of treatment, payment or health care operations, including, but not limited to:
- Planning for my care and treatment
- Calling me with appointment reminders and lab results
- Submitting a claim to my insurer or health plan
- Assessing the quality of care provided to me
WNA’S Notice of Privacy Practices contains a more complete description of how my Protected Health Information may be used or disclosed and how I can obtain access to this information. I understand WNA reserves the right to change its Notice and practices and I can request a copy of its current Notice.
I understand that I have the right to request restrictions as to how my Protected Health Information may be used or disclosed by WNA. WNA is not required to agree to my request but if WNA does agree, the requested restrictions will be binding on WNA.
I further understand that, at any time, I may revoke this consent in writing, except to the extent that WNA has already taken action in reliance on it.
USE OF TELEHEALTH FOR PHYSICIAN AND/OR CARE TEAM VISITS
By providing my consent, I agree to participate in telehealth visits with members of Washington Nephrology Associates team, including my physician and members of my physician’s practice group, and if applies, members of dialysis unit (Care Team) during the term of the national/state (i.e. COVID-19 pandemic). I understand certain steps are being taken to reduce the risk of potential exposure and spread of the virus, including the option to receive health care services via telehealth visits when appropriate. Some portions of my care may be reasonably provided via
telehealth instead of an in-person visit when my Care Team determines telehealth visits are appropriate for me. Reduced frequency of in-person visits may reduce my risk of potential exposure to the virus and may also help protect others. My Care Team will inform me if and when it is necessary to conduct an in-person visit. In such cases, my care team will follow all relevant policies, procedures, and infection control practices to reduce my risk of potential exposure I understand using telehealth services involves some increased risk that an unauthorized person may see, access, copy, or interrupt my personal information. I also understand there is some risk unencrypted electronic communications could be intercepted in transmission or misdirected to a third party not authorized to receive the information. I understand my Care Team may need to end, delay, or pause my telehealth session. I agree to cooperate with these interruptions and with directions given by my Care Team. I understand telehealth services are subject to the laws protecting the confidentiality of my medical information and my right to access that information. My Care Team will not share information obtained through telehealth if prohibited by federal or state law. I understand this consent will be effective until I am notified that this consent is no longer in effect because of resolution of the national and/or applicable state pandemic emergency. I may withdraw or revoke it at any time. I understand I have a right to receive a copy of this consent. I understand it is my choice to use telehealth visits and my decision to use, or not use, telehealth visits will not affect my right to future dialysis treatments. I understand my health benefits plan may not cover telehealth services and I may need to pay for telehealth visits, including copayments, co-insurance, or deductibles. I understand I am encouraged to discuss my telehealth service coverage with my health benefits plan.