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Attest's Medical Forms and Disclosures
Privacy policy, confidentiality statement
It is the policy of Attest Solution Experts and its affiliates (individually and collectively called ATTEST herein) that users (i.e., employees, staff, students, volunteers, contractors, vendors, outside affiliates, and any others who are permitted access to Attest Solution Experts information) shall respect and preserve the privacy, confidentiality and security of confidential information (“CI”) which shall include: individually identifiable patient information in any format including but not limited to paper and electronic medical and billing records. CI may be created internally or received from other institutions and may be in any format including paper, verbal/oral communication, audio recordings or electronic format. We understand and agree that Attest will only access, maintain, use, or disclose CI for legitimate job-related, need-to-know purposes. Attest further agree that: 1. It will protect the privacy, confidentiality, and security of Attest client information at all times in accordance with federal and state regulations and applicable Attest policies and procedures. Attest Solution Experts will not sell any protected health information to anyone or business, nor will we share your protected health information with anyone other than the necessary healthcare service provider(s) who will be providing medical services and treatment(s) to you.
Medical Agreement
I hereby authorize Attest Medical of Attest Solution Experts to obtain and collect any and all necessary information including my medical history to share with telemedicine (synchronous or asynchronous) providers for the purpose of administering medical services to me, the patient.
I understand that Attest Solution Experts is not a medical provider, but simply a consulting and servicing and referring company and hereby agree to take full responsibility for damages or harm that may occur from submitting my information, whether or not the information I provide is inaccurate, incomplete, or misleading. I understand the risk of misdiagnosis associated with utilizing tele-medicine due to the absence of a physical examination or an in-personal evaluation. I agree to follow up with a doctor for an in-person evaluation or call 911 if my symptoms worsen or do not improve in a timely manner.
Financial Disclosure
I understand that this consulting resource service fee may not cover the cost of my telemedicine provider consultation. I further understand that if I choose to pick up my medication(s) at a pharmacy, I still have to pay at that pharmacy. I have been informed that I can use my insurance at the pharmacy for my prescription. If my insurance fails to cover the prescribed medication, or test, or drug cost is unaffordable, I understand that I have to contact the telemedicine provider via email for an alternative drug or out of pocket (self-pay) options. I have been informed that the telemedicine consultation, and any drug(s) or follow-up procedures, tests, imaging, or laboratory cost or insurance limitations are NOT valid reasons to issue a refund. I understand that I, the patient, is financially responsible for my medical care and treatment including any and all associated laboratories tests, imaging, prescription(s), and follow-up visits and understands that it is my responsibility to familiarize myself with the pharmacy, and other facility's fees.
I understand that the resource service and/or consultation fee paid to Attest Solution Experts is for
providing a recommendation to a telemedicine provider and/or service, which may or may not
include collecting and sharing any and all of my necessary information needed for the
telemedicine provider’s service ONLY. I understand that I may still have to pay for the
telemedicine provider’s consultation as well as any additional fees and costs associated with my
care. I understand that the consultation and/or resource service fee paid to Attest Solution Experts is
NOT refundable. I hereby authorize Attest Solution Experts to release my information and/or a
copy of this agreement to my financial institution if I later dispute this charge.
I further understand that Attest Solution Experts is NOT responsible for any accidents,
malpractice or any mishaps that may occur as a result of using online and telemedicine services.
By signing below, I state that I have read, understood, and agreed to the terms of this agreement.
Financial Disclosure
An Attest Medical consulting resource and referral service fee may not cover the cost of my telemedicine provider consultation. Understand that if you choose to pick up medication(s) at a pharmacy, that you still have to pay at that pharmacy. You may be able to use insurance at the pharmacy for the prescription. If insurance fails to cover the prescribed medication, or test, or drug cost is unaffordable, you may contact the telemedicine provider via email for an alternative drug or out of pocket (self-pay) options. The telemedicine consultation, and any drug(s) or follow-up procedures, tests, imaging, or laboratory cost or insurance limitations are NOT valid reasons to issue a refund. The patient, is financially responsible for their medical care and treatment including any and all associated laboratories tests, imaging, prescription(s), and follow-up visits and are responsible to familiarize yourself with the pharmacy, and other facility's fees.
The resource referral service and/or consultation fee paid to Attest Solution Experts is for providing a recommendation to a telemedicine provider and/or service, which may or may not include collecting and sharing any and all of your necessary information needed for the telemedicine provider’s service ONLY. You may still have to pay for the telemedicine provider’s consultation as well as any additional fees and costs associated with your care such as prescriptions, imaging, labs etc. The consultation and/or reource referral service fee paid to Attest Solution Experts is NOT refundable and customers thereby authorize Attest Solution Experts to release their information and/or a copy of this agreement to their financial institution if they later dispute this charge.
Attest Solution Experts/Attest Medical is NOT responsible for any accidents, malpractice or any mishaps that may occur as a result of using telemedicine services.
HIPAA Authorization
I, the patient, hereby authorize the use or disclosure of my protected health information as described below:
1. AUTHORIZED PERSONS TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION
Attest Solution Experts is authorized to disclose the following protected health information to the Medical Consulting and Online Healthcare Provider Service, or Telemedicine Provider in which they deem necessary for my care.
2. DESCRIPTION OF INFORMATION TO BE DISCLOSED
The health information that may be disclosed is:
Medical records
Communicable diseases (including HIV and AIDS)
Alcohol/drug abuse treatment
Mental health records
All treatment records
Other: All requested and necessary details and records to provide adequate service
All past, present, and future periods of health care information may be shared.
3. PURPOSE OF THE USE OR DISCLOSURE
The purpose of this use or disclosure is so that I can seek medical care and treatment..
4. VALIDITY OF AUTHORIZATION FORM
This Authorization Form is valid beginning on this day and expires at the end of my care and
treatment.
5. ACKNOWLEDGMENT
I understand that the information used or disclosed under this Authorization Form may be subject to re-disclosure by the person(s) or facility receiving it and would then no longer be protected by
federal privacy regulations.
I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on me agreeing to this authorization.
I have the right to refuse this Authorization Form. If agreed, I have the right to revoke this authorization, in writing, at any time. I understand that any action already taken in reliance on this
authorization cannot be reversed, and my revocation will not affect those actions.
I, the patient, hereby authorize the use or disclosure of my protected health information as stated above.