Tele-support Informed Consent: Tele-support utilizes secure electronic communications, information technology, or other means to facilitate communication and the sharing of individual patient health information between a care facilitator and a patient at different locations. This "Tele-support Informed Consent" provides patients ("patient," "you," or "your") with information on the treatment methods, risks, and limitations associated with using a tele-support platform.
Services Provided: Tele-support services offered by Soulside and Soulside's engaged facilitators (our "Facilitators" or your "Facilitator") may include patient consultation and/or referral to in-person care as deemed clinically appropriate (the "Services").
Electronic Transmissions
The types of electronic transmissions possible through the tele-support platform include, but are not limited to:
- Appointment scheduling;
- Completion, exchange, and review of intake forms and other clinically relevant information (e.g., health records, sound and video files) between you and your Facilitator;
- Asynchronous text communications;
- Two-way interactive audio with store-and-forward communications; and/or
- Two-way interactive audio and video interaction;
- Recommendations based on the review and exchange of clinical information;
- Delivery of consultation reports with recommendations as clinically relevant;
- Recording and transcription of consultations;
- Other electronic transmissions for rendering clinical care to you.
Service Limitations:
- PROVIDERS DO NOT ADDRESS MEDICAL EMERGENCIES. IF YOU EXPERIENCE A MEDICALEMERGENCY, DIAL 9-1-1 AND/OR VISIT THE NEAREST EMERGENCY ROOM. DO NOT CONTACT SOULSIDE, OR YOUR PROVIDER FOR EMERGENCY HEALTHCARE.
- Facilitators complement, but do not replace, your local primary care provider. Responsibility for your overall medical care should remain with your local primary care provider, and we encourage you to have one if you do not already.
- Soulside does not operate any in-person clinic locations.
Security Measures:
The electronic communication systems used incorporate network and software security protocols to protect the confidentiality of patient identification, including measures to safeguard the data and ensure its integrity against corruption. All Services delivered via tele-support will occur over a secure connection compliant with the Health Insurance Portability and Accountability Act of 1996 ("HIPAA").
Possible Risks:
- Delays in evaluation and treatment could arise from equipment and technology deficiencies or failures, or facilitator availability.
- In case of communication failure due to technological or equipment failure, please contact Soulside at security@getsoulside.com.
- On rare occasions, transmitted information's quality may be deemed inadequate by your Facilitator, necessitating a rescheduled tele-support consult or an in-person visit with your local primary care doctor.
- Very rarely, security protocols might fail, leading to a breach of privacy of personal medical information.
Recording and transcription:
Tele-support and group chats, including video and voice calls are recorded and transcribed. These recordings are used to improve the quality of our Services and comply with HIPAA and our Privacy Policy.
Patient Acknowledgments
I acknowledge and understand that:
- In case of a medical emergency, I will dial 9-1-1 immediately, as my Facilitator cannot directly connect me to local emergency services.
- I have the right to withhold or withdraw my consent to use tele-support at any time and terminate my relationship with Soulside.
- Soulside will take steps to ensure my health information is not seen by unauthorized individuals. Tele-support may involve the electronic communication of my personal health information to other health practitioners, including those out of state. I consent to Soulside using and disclosing my health information for treatment, care coordination, reimbursement, and healthcare operations purposes.
- No dissemination of patient-identifiable images or information from the tele-support visit will occur without my consent, unless authorized by law.
- The risk of technical failures during the tele-support visit is acknowledged, though beyond Soulside's control.
- Others may be present during the tele-support visit for operational reasons; I will be informed of their presence and roles.
- I have the right to request a copy of my medical records from Soulside by contacting privacy@getsoulside.com. Copies will be provided at a reasonable cost.
- Providing a complete, accurate, and current medical history is necessary. I can request changes or amendments to my medical record by contacting Soulside.
- There is no guarantee of treatment by a Soulside Facilitator. My Facilitator reserves the right to deny care if deemed medically or ethically inappropriate.
Additional State-Specific Consents: State-required consents for patients accessing Soulside's website for tele-support consultations are acknowledged.
NOTICE OF PRIVACY PRACTICES - SOULSIDE AFFILIATED COVERED ENTITY
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED ANDHOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
This Notice of Privacy Practices ("Notice") outlines how Soulside and all members of its Affiliated Covered Entity (collectively, "Soulside," "we," or "our") may use and disclose your protected health information for treatment, payment, business operations, and other law-permitted or required purposes. An Affiliated Covered Entity is a group of healthcare facilitators under common ownership or control that designates itself as a single entity for HIPAA compliance purposes. Although not a "Covered Entity" under HIPAA, we voluntarily comply with HIPAA standards. Members of the Soulside Affiliated Covered Entity will share protected health information for treatment, payment, and healthcare operations of the Affiliated CoveredEntity as permitted by HIPAA and this Notice.
"Protected health information" or "PHI" refers to information that may identify you and relates to your past, present, or future physical health, treatment, or payment for healthcare services. This Notice also details your rights regarding access and control over your PHI.
USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION:
Your PHI may be used and disclosed by our healthcare facilitators, staff, and others outside our office involved in your care and treatment, to support our business operations, to obtain payment for care, and for other authorized or required uses and disclosures.
TREATMENT: Your PHI will be used and disclosed to provide, coordinate, or manage your care and any related services, including coordination with third parties. For example, PHI may be shared with a facilitator to whom you have been referred to ensure they have the necessary information to engage with you.
PAYMENT: Your PHI may be used to bill or obtain payment for healthcare services. This includes activities your health insurance plan may undertake before approving or paying for services, such as eligibility or coverage determinations and medical necessity reviews.
HEALTH CARE OPERATIONS: We may use or disclose your PHI as needed to support our business activities. These include quality improvement, treatment alternatives or health-related benefits and services information, computer systems development and maintenance, legal services, audits, compliance programs, and fraud, waste, and abuse investigations.
USES AND DISCLOSURES THAT DO NOT REQUIRE YOUR AUTHORIZATION: Your PHI may be used or disclosed without your authorization in situations required by law; for public health purposes; healthcare oversight; abuse or neglect reporting; Food and Drug Administration requirements; legal proceedings; law enforcement purposes; coroners, funeral directors, organ donation; research; allegations of criminal activities; military activity and national security; workers' compensation; inmate reporting; and other required uses and disclosures. Certain disclosures may be further restricted by state laws.
USES AND DISCLOSURES THAT REQUIRE YOUR AUTHORIZATION: Uses and disclosures not covered by this Notice or laws will be made only with your consent, authorization, or opportunity to object. Without your authorization, we cannot use or disclose your PHI for marketing, sell your PHI, or share psychotherapy notes, except as permitted by law. You may revoke any authorization in writing, except to the extent action has already been taken.
YOUR RIGHTS REGARDING PHI: You have rights to request restrictions on use or disclosure of your PHI, receive confidential communications, access, inspect, and copy your PHI, request amendments, receive an accounting of certain disclosures, and obtain a paper copy of this Notice. Requests must be in writing, and we are not required to agree to all requests, except for paid-out-of-pocket services' payment or healthcare operations disclosures.
REVISIONS TO THIS NOTICE: We reserve the right to revise this Notice and make the revised Notice effective for PHI we already have and any information we receive in the future. You are entitled to the current Notice. Significant changes will be posted on our website.
BREACH OF HEALTH INFORMATION: You will be notified if there is a breach of your unsecured PHI within 60 days of discovery, including a description of the breach, the PHI involved, and contact information for questions.
COMPLAINTS: Complaints about this Notice or our handling of your PHI should be directed to our HIPAA Privacy Officer. You may also file a complaint with the Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you for filing a complaint.
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES: By clicking and typing your name below, you acknowledge receipt or the opportunity to receive the Soulside Affiliated Covered Entity's Notice of Privacy Practices.
