I voluntarily request and authorize the physician(s), and/or Advanced Practice Provider (Nurse Practitioner, Physician Assistant or Clinical Nurse Specialist), and other health care providers or the other designees of Summa Health Medical Group, as deemed necessary, to perform a telemedicine e-visit through the use of interactive audio, store and forward technologies and secure internet video. .
I agree that this consent provides Summa Health Medical Group with my permission to perform reasonable and necessary medical examinations, testing and treatment. By signing below I am indicating that:
This consent will remain in effect for one year unless earlier revoked in writing by me, the patient.
I understand that the practice of medicine is not an exact science and acknowledge that no guarantees have been made to me regarding the likelihood of success or outcomes of any e-visit.
I understand the benefits of telehealth include, but are not limited to, easier and quicker access to providers, even at a distance. As with any medical treatment, telehealth has some risks. I understand that the risks of telehealth include, but are not limited to, insufficiency or delays in information capable of being transmitted and, therefore, inability to properly or timely treat a condition. Finally, I understand that being treated by a practitioner who may have incomplete access to my complete medical history could result in adverse drug reactions or interactions or other judgment errors. I understand that these are not all of the risks, but just some of the material risks. I acknowledge and agree that no guarantee or assurances have been made to me concerning the results of telehealth. I have been informed of the alternatives to telehealth and consent to proceed with a telehealth consultation.
I acknowledge and understand that I have the right, as a patient, to be informed about my condition and the recommended surgical, medical or diagnostic procedure(s) to be used so that I may make the decision whether or not to undergo any suggested treatment or procedures after knowing the risks and hazards involved. I also have the right and the responsibility to participate in my care and treatment – including the responsibility to ask questions if I do not understand something and provide Summa Health Medical Group with accurate and complete information about my health history and presenting complaint, to agree upon a treatment plan, and to follow that plan. I also have the right at any time to revoke this consent and discontinue services.
I certify that I have read and fully understand the above statements, have had the opportunity to ask questions and consent fully and voluntarily.
Effective: February 4, 2020
SUMMA MAY REVISE THIS POLICY AT ANY TIME. SHOULD ANY NEW POLICY TAKE EFFECT, SUMMA WILL GIVE NOTICE TO YOU AND ALL USERS BY POSTING A NOTICE REGARDING THE NEW POLICY ON THIS PLATFORM, AND THE NEW POLICY WILL APPLY ONLY TO INFORMATION COLLECTED THEREAFTER. NEW POLICIES WILL BE EFFECTIVE AS OF THEIR POSTING UNLESS OTHERWISE STATED.
BY ACCESSING OR USING THIS PLATFORM AFTER SUCH CHANGES ARE POSTED YOU AGREE AND CONSENT TO ALL SUCH CHANGES.
If you are a patient or legal representative, the Providers’ use and disclosure of your identifiable health information is subject to the Providers’ Notice of Privacy Practices. The SUMMA Notice of Privacy Practices is available at https://www.summahealth.org/patientvisitor/patient-support/noticeofprivacy.
Disclosure of Information Practices
The amount and type of information that we receive depends on how you use this Platform and the information you choose to submit to us via the Platform.
Whether you are a patient (or legal representative) or a Provider-affiliated physician, we may track use of your user name and may also capture the paths taken as you move from page to page (i.e., your "click stream" activity). When you log in, your user name and password will be logged by our system in an audit log.
As a user of the Platform, you may also choose to use the secure messaging feature of the Platform, which allows the exchange of communications between patients and Providers and which may contain identifiable health information. Communications sent via this feature are recorded and maintained by SUMMA. Platform users have the ability to view the trail of messages received and sent via their Platform account. SUMMA does not edit the content of the communications between patients and Providers.
Personally Identifiable Information
You may request additional information about the Platform and the Services by submitting your information to us or otherwise contacting us as set forth on the Platform. If you elect to send us your contact information, we will use your contact information to provide you the information you requested and otherwise communicate with you to respond to your inquiry.
Identifiable Health Information
If you are a patient or the legal representative of a patient, you must provide certain identifiable health information and medical history in order to complete your registration for Platform to request Services, such as behavioral health or other medical consultations provided by the Providers.
If you are a patient (or the legal representative of a patient), we will collect identifiable health information from you during the registration process and in the event you later request information or Services. We may collect any identifiable information that you provide to us, such as your name, address, e-mail address, gender, birth date and phone number. We also need your medical history in order for you to request Services.
When you register for the Platform via the Platform, the registration process requires you to choose a user name and password for your account, which you should keep and maintain as confidential. If you choose to share your user name and password you understand that those individuals to whom you share that information will have access to your identifiable health information and will be able to add to your identifiable health information as though they were you. You will be responsible for all activities by users resulting from sharing or not maintaining the confidentiality of your user name or password.
If you are a registered patient user of the Platform, your identifiable health information (or that of the patient for whom you are the legal representative) will become accessible to SUMMA in order to provide you access to such information through the Platform. This information includes the information you provide to SUMMA for us to share with Providers and information uploaded to the Platform by Providers related to any Services.
Non-Identifiable Health Information
Either SUMMA or our third party vendor on behalf of SUMMA may also collect non-identifiable information, which is automatically collected as you browse or otherwise access the Platform. We may collect such information by tracking, or asking our third party vendor to track, your click-stream activity when such information is not tied to a user ID through the use of "cookie" technology or by tracking internet protocol (IP) addresses, as explained below.
Like many companies, we may use "cookie" technology on and off of the Platform. “Cookies” are small pieces of information that are stored by your browser on your computer’s hard drive. They enhance your online experience by saving your preferences while you are visiting a particular website. The cookies do not contain any identifiable health information and cannot profile your system or collect information from your hard drive.
When you view or access our Platform we may place a cookie on your computer, which may be either temporary or permanent. Temporary cookies are used to complete transactions with this Platform and for other purposes such as counting the number of visits to our certain web pages. These temporary cookies are eliminated when you exit your browser.
A permanent cookie may also be stored on your computer by your browser. When you log in, this type of cookie tells us whether you've visited us before or if you are a new visitor. The cookie doesn't obtain any identifiable health information about you or provide us with any way to contact you, and the cookie doesn't extract any information from your computer.
The "help" portion of the toolbar on most browsers will tell you how to prevent your browser from accepting certain types of cookies, how to have the browser notify you when you receive a new cookie, or how to disable cookies altogether. Please note that disabling temporary cookies may prevent you from using and accessing this Platform. Disabling permanent cookies may also impact your use and access of the Platform and in particular will not allow you to see any personalization on the Platform that you may activate.
In addition, if you visit our Platform again after deleting a cookie, a new cookie may be activated.
We may also log and track IP addresses for systems administration purposes and for reporting usage trends. Your IP address is usually associated with the physical place from which you enter the Internet, the name of the domain and host from which you access the Internet, the browser software you use and your operating system, and may also depend on the date and time you access the Platform. By collecting your IP address, we may record the page that linked you to this Platform, the web pages you visit within the Platform, the ads you see or click on within the Platform, and other information about the type of web browser, computer, platform and settings you are using, and any search terms you enter on this Platform. IP addresses are not used to track an individual user’s session. This information helps us determine how often different areas of our Platform and Platform are visited.
We may combine non-identifiable information collected automatically (such as through IP addresses, cookies or click-stream monitoring) with any previously submitted personal information that we may have received from you.
We may collect your geographic location based on your IP address and other location-based data. However, we do not collect any device identifications.
We may also use various third party internet vendors to collect, track and analyze track analytical data regarding Platform usage and trends.
Users of the Platform may have the opportunity to participate through the Platform in various SUMMA surveys regarding use of the Platform and receipt of the Services.
If you choose not to receive survey invitations through the Platform you may change your privacy settings within the Platform.
Any survey responses that you choose to submit may be aggregated, deidentified and provided or sold to third parties as set forth below.
How Will Your Information Be Used And Disclosed?
Identifiable Health Information
We may use any identifiable health information or other information that you voluntarily provide us in order to provide you with information, products or services that you may request from SUMMA or the Providers.
If you are a patient or the legal representative of a patient, any identifiable health information that you share via the Platform will be made accessible to the Provider and will become a part of the records maintained by SUMMA on behalf of the Providers, which records are subject to the Providers’ Notice of Privacy Practices. Any information generated by the Providers in providing the Services will be provided back to SUMMA by the Providers and will also become part of the records maintained by SUMMA. SUMMA
We may also use your identifiable information to send you appointment reminders or other notifications regarding the Services. If you elect to provide us a cell phone number, you expressly consent that we can provide these communications to you via text message. Data or text charges may apply. You may change your preferred method of communication in your “My Account” setting.
To the extent permitted by applicable law, SUMMA may use your information to communicate to you special offers and featured items from third parties, SUMMA, SUMMA's affiliates, and/or other suppliers and vendors. If you are receiving additional communications and special offers, you may revoke your authorization to receive such materials from SUMMA via the Platform at any time by contacting us using the contact information below or as outlined in the applicable communication. We will implement your revocation as soon as is commercially reasonable and as required by law. SUMMA cannot control any communications and other materials that you may receive directly from third parties.
We will also use your information to customize your browsing experience and communicate with you and otherwise respond to your questions and suggestions regarding use of the Platform as may be permitted by applicable law.
We will share your information only with the Providers and our suppliers and vendors to the limited extent necessary to provide this Platform and the Services. We require those suppliers and vendors to comply with all applicable data privacy laws and regulations, including HIPAA. We do not sell, lease or rent your identifiable health information.
Non- identifiable Health Information
The non- identifiable health information we collect may be deidentified and shared with our suppliers and vendors and used in the aggregate to create summary statistics that help us analyze Platform usage trends, assess what information is of most and least importance, determine technical design specifications, arrange the Platform in the most user-friendly way, and identify system performance or problem areas.
We may also use your geographic location to provide you with specific content and direct you to your closest service providers to the extent permitted by applicable law.
We may aggregate and de-identify identifiable health information in accordance with HIPAA, either alone or with other data to create anonymous "aggregate data" regarding the users of our Platform. Aggregate and deidentified data is information that describes the habits, treatment plans, usage patterns and/or demographics of users as a group but does not reveal the identity of particular users. This data will not identify you, but will be used as statistical information to determine such things as user demographics and usage patterns of our Platform. SUMMA may use aggregate data to understand the needs of our community of users and determine what kinds of programs and services we can help provide. Aggregate data may also be provided or sold to third parties, including to give third party vendors, suppliers, business partners and/or affiliates a picture of our community and services.
Other Use and Ownership
We also reserve the right to share your information collected from this Platform with third parties to the extent permitted by applicable law and, in the case of identifiable health information, pursuant to SUMMA's business associate agreement with the applicable Provider.
Transfer of Data
While no web site can guarantee security, we maintain physical, administrative, electronic, technical and procedural safeguards to help protect your personal information collected via the Platform as required by applicable law. While we cannot guarantee that loss, misuse or alteration to data will not occur, the Platform uses industry standard technology, such as Transport Layer Security (“TLS”), to help safeguard against such occurrences. In certain areas, the information passed between your browser and our system is encrypted with TLS technology to create a protected connection between you and our website to ensure confidentiality.
Our data center is both physically and electronically secured. Our servers are protected behind the Internet by using firewall and encryption technology. All data is stored and transferred in encrypted formats that exceed standards defined by HIPAA. No data is transferred to users that do not have specific data access keys.
We limit access to personally identifiable information about you to our employees and third-party agents, who we reasonably believe need to have access to your information to provide you with the information or services you request via the Platform.
In the event that a breach in our security systems occurs and there is a possibility that an unauthorized person acquires your personal information, we will notify you of such a breach as may be required by applicable law.
In order to help maintain security, you should never share your user ID or password and should always sign out when you are finished using the Platform.
We will maintain your information and allow you to request updates at any time by logging into your Platform account to access your information. We will also take steps to make sure that any updates that you provide are processed in a timely and complete manner.
Third Party Platforms
What if I am accessing this Platform from outside of the United States?
Summa is located in the United States, as are the Providers who provide Services under the Portal pursuant to each Provider’s credentials within the United States. The Platform is directed solely to individuals located in the United States and we rely upon your representation of which U.S. state you are located in order to connect you with Providers credentialed in your state. While Summa, its third party vendor, and/or its Providers may offer language translation services, such services are intended to assist individuals seeking our services within the United States and are not directed to individuals in any foreign country.
In the event we offer services that are subject to the General Data Protection Regulation (GDPR), we will comply with requests which could include the right to access information we hold about you, have inaccurate or unnecessary information rectified or deleted or to ask us to stop using your information in a certain way. In the unlikely event your use of the Services is subject to GDPR, you would also have a right to lodge a complaint with your local EU regulator.
Important Note Regarding Children
This Platform and Platform is not directed toward children under 18 years of age and SUMMA does not knowingly collect information from children under 18 through this Platform or Platform. Any information submitted via the Platform regarding a minor under the age of 18 must be submitted by the minor's legal representative. To the extent permitted by applicable state law, minors may access their identifiable health information through their physician.
Summa Physicians, Inc. d/b/a Summa Health Medical Group
525 East Market Street
Akron, Ohio 44304