This MEMBER AGREEMENT (this “Agreement”) is entered between the undersigned party (“you” or “Member”) and Steady Health Medical Group (the “Medical Practice”).
You are eighteen (18) or older and have requested medical treatment and services from Medical Practice pursuant to this Agreement.
Medical Practice renders medical services through physicians duly qualified and licensed to practice medicine in the state of California (each a “Medical Practice Physician”), and through other duly licensed medical providers, such as nurse practitioners and physician’s assistants (each a “Medical Practice Provider”). Medical Practice Physicians and Medical Practice Providers are sometimes referred to collectively herein as “Health Care Professionals.”
This Agreement will take effect on the date that you accept this Agreement or the date you first receive services from Medical Practice under this Agreement (the “Effective Date”).
The parties agree to enter into this Agreement in accordance with the following terms and conditions:
Physician-Patient Relationship. You acknowledge that a physician-patient relationship is not established until you have been seen by a Medical Practice Physician. To facilitate communication and services provided by Health Care Professionals, Medical Practice licenses access to a proprietary mobile and web-based application (the “Steady App”) from an independent third party, Steady Health, Inc. Requesting services through the Steady App does not create a physician-patient relationship.
The Services. You are entering into this Agreement because you are at least eighteen (18) years old, have requested medical services through the Steady App, and you have been connected to a Health Care Professional to receive individualized health care services (your “Treatment”).
Consent to Services.
By entering into this Agreement you agree that you have requested to receive medical treatment and services in exchange for payment to Medical Practice. You consent to the rendering of medical treatment and services as considered necessary and appropriate by your Medical Practice Physician at the time of your Treatment. You have the right to decline treatment and services at any time during the course of your Treatment but you may be responsible for paying for services already rendered.
You acknowledge that no assurances or guarantees have been made to you by Medical Practice or the Health Care Professionals concerning the outcome and/or results of any medical treatment or services.
During the course of your Treatment, the Health Care Professionals may discuss details of your medical or health history or personal health information. You may also be asked for proof of identify with a driver’s license or other legal document.
You should seek emergency help or follow-up care when recommended by your Medical Practice Physician, and it is your responsibility to consult with your primary care physician or other healthcare professional as recommended during or following your Treatment. Medical Practice shall have no responsibility for the actions or omissions of your primary care physician or other health care provider, or for any consequences arising from your failure to seek appropriate medical treatment.
Unable to Treat. Under certain limited circumstances, a Medical Practice Physician may determine, in his or her best judgment, that he or she is unable to provide medical treatment and services to you, based on information received or conduct occurring during the course of your Treatment; provided, however, that in no case shall a Medical Practice Physician make such a determination based on a member’s sex, sexual orientation, race, creed, color, national origin or disability.
Payment for Services. To obtain your Treatment, you must be a member of the Steady Health program (a “Steady Health Member”). You become a Steady Health Member by (a) downloading the Steady App, and (b) by submitting a personal credit card payment of $59 (the “Membership Fee”) through the Steady App. Your membership will be effective at the time your payment is processed. The Membership Fee includes membership for one month, after which your membership will be automatically renewed without notice on a monthly basis by charging the personal credit card currently on file with the Steady App. You may cancel your membership at any time by chatting with your care team through the Steady App or emailing email@example.com. Cancellation is not complete until you receive written confirmation and cancellation will be effective as of the first day of the month following the month in which your Membership Fee was last paid.
Medical Practice generally charges on a fee-for-service basis for the service provided in the course of your Treatment, or by some other fee schedule negotiated between Medical Practice and certain contracted health plans (the “Service Fee”). Any Service Fee or portions thereof that are your responsibility (including any applicable copayments or deductibles) must be made by personal credit card through the Steady App. If you are a member of an insurance plan that contracts with Medical Practice as an in-network provider, and your insurance coverage has previously been verified, Medical Practice will bill the insurance plan for the portion of the Service Fee for which it is responsible. MEDICAL PRACTICE DOES NOT PARTICIPATE IN MEDICARE OR MEDICAID. BY SIGNING BELOW, YOU ACKNOWLEDGE THAT YOU ARE NOT A MEDICAID BENEFICIARY. If a Medical Practice Physician determines he or she is unable to provide your Treatment after payment is made, Medical Practice may refund all or a portion of the payment made, in its reasonable discretion.
Accuracy of Information. It is imperative that you provide accurate and truthful information about your identity and your health and physical condition during the registration process and to the Health Care Professionals. You represent and warrant to Medical Practice that all of the personal information you provide during this process is true and correct. Medical Practice and the Health Care Providers reserve the right to refuse to provide services if Medical Practice determines you have not provided complete and accurate health information.
Email and Electronic Communications. By entering into this Agreement, you consent to the use of unsecured email, mobile phone text message, or other electronic methods of communication (“E-messages”) between you and Medical Practice and the Health Care Providers for purposes of discussing personal material relevant to your treatment or health records. You understand that E-Messages are typically not confidential means of communication and that there is a reasonable chance that a third-party may be able to intercept and see these messages (including people in your home or work who can access or view your phone, computer, or other devices, and/or third parties on the Internet such as server administrators and others who monitor Internet traffic). You have been informed of the risks, including but not limited to the risk with respect to the confidentiality of your treatment, of transmitting your protected health information by an unsecured means.
Remote Patient Monitoring.
General. My Medical Practice Physician may determine that is medically necessary for my specific medical condition to use certain third-party health monitoring devices and/or sensors that measure and/or collect certain data points relating to my health or wellness, such as blood glucose levels (collectively, the devices and sensors are referred to herein as, “Devices,” my personal information that is measured and collected by the Devices is referred to as “My Information,” and the collection and transmission of My Information is referred to as “Remote Monitoring”). In the event that I participate in Remote Monitoring, I will review and separately sign the “Remote Patient Monitoring Consent Form” attached hereto.
No Emergency Response Service. I understand that Remote Monitoring is intended to provide Health Care Professionals with a more complete picture of my health and is not intended for any purpose other than health monitoring. I understand that Remote Monitoring does not constitute an emergency monitoring or notification service, and that Medical Practice does not provide emergency services. I am aware that there is no guarantee that My Information will be reviewed on a 24/7 or any other minimum basis.
Purchase of Equipment. If my Medical Practice Physician determines that Remote Monitoring is medically necessary given my specific health condition(s) then I may be required to purchase Devices that Medical Practice does not provide to realize the full benefit of the Remote Monitoring. I understand that Medical Practice is not giving or offering to give me any Device.
Limitations on Use. I am the only one who is authorized to use any of the Devices used by me for Remote Monitoring. I agree that I will use all such Devices as instructed and as intended by Medical Practice. I will not tamper with any such Devices.
I understand that Medical Practice is not affiliated with, and does not otherwise control, any third-party vendors that produce software or hardware involved in Remote Monitoring. I agree that Medical Practice is not responsible for any of the products of those third-party vendors or the accuracy of any data received from them, including the accuracy of My Information. Medical Practice makes no representations or warranties regarding the use of, or interaction with, such third-party systems, software, hardware, or data and I understand and agree to look solely to such third-party vendors for any claims relating to my use of such software or hardware.
Secure Transmission of My Information. I am aware that My Information will be transmitted from applicable Devices to Medical Practice. Once My Information is received, Medical Practice will ensure my data is securely stored in a manner that, at a minimum, is in compliance with applicable state and federal laws.
I understand that My Information may run through third-party servers during the course of Remote Monitoring. Medical Practice will enter into agreements with its third-party vendors to ensure that My Information is securely transmitted and stored in compliance with applicable state and federal laws.
Finally, I agree that Medical Practice is not responsible for the security of My Information stored by any third-party, unless that third-party is storing My Information at the explicit request and direction of Medical Practice.
Coordination with Health Records and Health Data. In an effort to gain a more complete picture of your health, Medical Practice supports coordinating access to your health records and health data that may be created by various third-party sources throughout the course of your Treatment. This may include access to (a) your patient health records from other providers and/or (b) your electronic health data created by your use of different wellness, fitness, or medical devices. To allow for this coordination to be done wirelessly, you can connect your account in the Steady App with outer third-party platforms or products that will share your information with the Steady App. Medical Practice will be able to see any of your records and data that are shared with the Steady App. Your information will only be shared with Medical Practice in this manner as long as your account remains connected. You may disconnect your account from any third-party platforms or products at any time. Because Medical Practice is not affiliated with any applicable third-parties, it makes no representations or warranties about such platforms or products, and Medical Practice is not responsible for the accuracy of your health records or health data created by third-parties.
Term of Agreement. This Agreement shall take effect on the Effective Date and shall last for a term of one year following the date of your last Treatment.
Assignments. Your interests under this Agreement are personal to you, and you may not assign your rights under this Agreement without the prior written consent of Medical Practice. Medical Practice may assign its rights and obligations under this Agreement without prior written consent of the Member.
Indemnification. By entering into this Agreement, you acknowledge and agree that you shall be liable for, and shall indemnify, defend and hold harmless Medical Practice from any and all liability, loss, claim, lawsuit, injury, cost, damage or expense whatsoever (including reasonable attorneys’ fees and court costs) arising out of, incident to or in any manner occasioned by your performance or nonperformance of any of your duties or responsibilities under this Agreement, but only to the extent, and only in such amount, that such liability, loss, claim, lawsuit, injury, cost, damage or expense is not covered and paid by third party insurance.
Severability. The provisions of this Agreement shall be deemed severable and if any portion shall be held invalid, illegal or unenforceable for any reason, the remainder of this Agreement shall be effective and binding upon the parties.
Entire Agreement. This Agreement, including all corresponding attachments and exhibits represent the entire agreement between you and Medical Practice, and no other agreements, oral or written, have been entered into with respect to my Treatment and services provided by Medical Practice. This Agreement supersedes all prior agreements and communications of whatever type, whether written or oral, regarding your Treatment and services provided by Medical Practice. This Agreement may be executed in counterparts, each of which shall be deemed an original, but all such counterparts together shall constitute one and the same instrument. The exchange of copies of this Agreement by electronic means shall constitute effective execution and delivery of this Agreement as to the parties and signatures of the parties transmitted by electronic means shall be deemed to be their original signatures for any purposes whatsoever.
Notice of Amendment. This Agreement may be amended by Medical Practice upon provision of thirty (30) days prior notice to Member.
Waiver. No delay or omission by either party to exercise any right or remedy under this Agreement shall be construed to be either acquiescence or the waiver of the ability to exercise any right or remedy in the future. Any waiver of any terms and conditions hereof must be in writing, and signed by the parties hereto. A waiver of any term or condition hereof shall not be construed as a future waiver of the same or any other term or condition hereof.
Governing Law. This Agreement shall be governed by and construed in accordance with the laws of the State of California.
Disclosure of Physician Information. By entering this Agreement you acknowledge that you have received information regarding the applicable Medical Practice Physician’s name and license number, license status, highest level of academic degree, and board certification. Each Medical Practice Physician is licensed to practice medicine in the state of California and may be a board certified physician or a licensed physician in his/her final year of residency who is not yet board-certified. You are encouraged to contact the Medical Board of California per the below contact information should you have any questions or concerns.
Medical doctors are licensed and regulated
by the Medical Board of California
NOTICE OF PRIVACY PRACTICES
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
Specifically, this notice describes the privacy practices of Steady Health Medical Group, the independent professional medical entity that contracts with Steady Health, Inc. (“Steady”), operates as a covered entity, and provides the requested medical services. Among other things, Steady Health Medical Group contracts with Steady to license Steady’s Application to provide Steady Health Medical Group with the capability to receive, respond to and schedule requested visits. Steady does not provide any medical services, nor does it refer or recommend any physician or medical practice or any other medical provider or personnel.
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
Get an electronic or paper copy of your medical record
You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct your medical record
You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
We may say “no” to your request, but we’ll tell you why in writing within 60 days.
Request confidential communications
You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
We will say “yes” to all reasonable requests.
Ask us to limit what we use or share
You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.
Get a list of those with whom we’ve shared information
You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Get a copy of this privacy notice
You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
Choose someone to act for you
If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
We will make sure the person has this authority and can act for you before we take any action.
File a complaint if you feel your rights are violated
You can complain if you feel we have violated your rights by contacting us using the information on page 1.
You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
We will not retaliate against you for filing a complaint.
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
In these cases, you have both the right and choice to tell us to:
Share information with your family, close friends, or others involved in your care
Share information in a disaster relief situation
Include your information in a hospital directory
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
In these cases, we never share your information unless you give us written permission:
Sale of your information
Most sharing of psychotherapy notes
In the case of fundraising:
We may contact you for fundraising efforts, but you can tell us not to contact you again.
Our Uses and Disclosures
How do we typically use or share your health information?
We typically use or share your health information in the following ways.
We can use your health information and share it with other professionals who are treating you.
Example: A doctor treating you for an injury asks another doctor about your overall health condition.
Run our organization
We can use and share your health information to run our practice, improve your care, and contact you when necessary.
Example: We use health information about you to manage your treatment and services.
Bill for your services
We can use and share your health information to bill and get payment from health plans or other entities.
Example: We give information about you to your health insurance plan so it will pay for your services.
How else can we use or share your health information?
We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html
Help with public health and safety issues
We can share health information about you for certain situations such as:
Helping with product recalls
Reporting adverse reactions to medications
Reporting suspected abuse, neglect, or domestic violence
Preventing or reducing a serious threat to anyone’s health or safety
We can use or share your information for health research.
Comply with the law
We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.
Respond to organ and tissue donation requests
We can share health information about you with organ procurement organizations.
Work with a medical examiner or funeral director
We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
Address workers’ compensation, law enforcement, and other government requests
We can use or share health information about you:
For workers’ compensation claims
For law enforcement purposes or with a law enforcement official
With health oversight agencies for activities authorized by law
For special government functions such as military, national security, and presidential protective services
Respond to lawsuits and legal actions
We can share health information about you in response to a court or administrative order, or in response to a subpoena.
Special Categories of Information
In many circumstances, we are required to provide more restrictive treatment to the following types of information: psychotherapy notes, genetic testing information, information on persons with developmental disabilities, information concerning HIV/AIDS testing, and alcohol and drug abuse treatment.
We are required by law to maintain the privacy and security of your protected health information.
We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
We must follow the duties and privacy practices described in this notice and give you a copy of it.
We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html
Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.
If you have any questions or comments about this Policy, please email us at firstname.lastname@example.org or send us a letter at:
ATTN: Privacy Officer
100 Bush Street,
San Francisco, CA 94104
This note is effective as of 04/07/2019
Remote Patient Monitoring Consent
I hereby consent, to receiving remote patient monitoring services from Aaliya H. Yaqub, M.D., P.C. aka Steady Health Medical Group (“Medical Practice”) as part of my health evaluation and treatment, and I further give Medical Practice and its providers permission to consult with relevant specialists as needed during the course of my treatment. I am providing the foregoing consents based on my understanding of the following:
During the remote patient monitoring process, my provider and I will be in different physical locations and my medical and/or health information will be communicated to health care providers at those other physical locations. I may benefit from the use of remote patient monitoring, but results cannot be guaranteed or assured.
I have the right to terminate Medical Practice’s remote patient monitoring services at any time without affecting my right to future care or treatment or risking the loss or withdrawal of any program benefits to which I would otherwise be entitled.
I will be responsible for any applicable cost sharing amounts (including deductibles, copays and/or coinsurance) for remote patient monitoring services. These amounts are determined by the terms of my health plan or health insurance agreement and not by Medical Practice.
The information and data disclosed by me during the course of my participation in Medical Practice’s remote monitoring services may be integrated into my medical record and will generally be protected and confidential. However, I understand that there is a risk that data security protocols could fail, which could result in the unintended disclosure of my information.
Only one practitioner or facility, as applicable, may provide and be paid for remote monitoring services during a calendar month. I am not participating in remote monitoring services with any of my other medical providers.
In some states, including California, remote patient monitoring may be considered a type of “telehealth.” My consent is therefore intended to satisfy any and all legal requirements that apply to the use of telehealth, including without limitation, Section 2290.5(b) of the Cal. Bus. & Prof. Code.
I have discussed the foregoing information with my provider and all of my questions have been answered to my satisfaction.
By agreeing to the Member Agreement in the Steady App, you agree to the above terms and conditions. Your acceptance represents you have received and read the terms and conditions, and you acknowledge that you have a right to receive a copy of this Agreement.