Terms of service

I understand that my health and wellness provider HealthBrew wishes me to have a telehealth consultation.

Our goal is to make it as easy as possible to access great care from a licensed healthcare provider by using our platform. Telehealth involves the delivery of healthcare using technology, when a patient is in one location and a provider is in another location (typically through a video visit). Providing healthcare through technology is called "telehealth." Below we outline the potential benefits and risks of telehealth and ask you to consent to its use. We want to provide you with information around the benefits and the risks, and we want you to make an informed decision about your care.

I understand how telehealth will be used to do such consultation and how else I will use telehealth to connect while working together, using the Healthie telehealth platform

I understand there are potential risks with this technology:

• The video connection may not work or it may stop working during the consultation.
• The video picture or information transmitted may not be clear enough to be useful for the consultation.
• The technology is limited in its ability to conduct a physical exam or assess vital signs and is not suitable to identify the need for emergency care.
• Delays in medical evaluation or treatment could occur due to unavailability of providers or failures of the technology or electronic equipment used.
• In rare instances, security protocols or safeguards could fail, causing a breach of privacy.

The benefits of a telehealth consultation are:

• I do not need to travel to the consult location and I am able to avoid unnecessary travel.
• I have access to a specialist through this consultation and the services they offer.
• I have flexibility to schedule digital communication and telehealth visits at convenient times and I am able to reduce my wait time to see a specialist.

I also understand other individuals may need to use the Healthie telehealth platform and that they will take reasonable steps to maintain confidentiality of the information obtained. I have read this document and understand the risk and benefits of the telehealth consultation and have had my questions regarding the procedure explained and I hereby consent to participate in telehealth sessions under the conditions described in this document.

Confidentiality

• I agree to keep confidential the names of other members of HealthBrew and what is said in a group setting. As a member of this group, I agree to not disclose to anyone outside the group any information that may identify another group member. This includes, but is not limited to, names, physical descriptions, biological information, and specifics to the content of interactions with other group members.
• I agree to indemnify and hold HealthBrew Clinic harmless for any loss or damages, including costs and attorney’s fees, incurred by HealthBrew as a result of my breach of another’s confidentiality.
• Confidentiality of audio and video communications in individual and group counseling sessions are protected by encryption and on a secure site. I understand that efforts to keep all information confidential are made, and likewise, I will take steps to safeguard my Healthie account login information. I will not share my login with anyone or give them access to my account or virtual sessions.
• I agree not to record any audio or visual communication transmitted via the site or app including telehealth services, without the express consent of all communicating parties. 
• I agree not to use unsecured public wi-fi or other unsecured electronic communication.

Additional Agreements:

• I give permission to HealthBrew Clinic to care for me. I may withdraw this consent at any time by no longer seeking services from HealthBrew Clinic.
• I understand that the problem I am seeking care for may not be resolved and I may need to seek care with a different provider or possibly an in-person clinic. 
• I understand that my primary doctor is not HealthBrew Clinic. Instead I am seeking specialty care for the services they do provide as specialists. 
• I understand that it is up to me if I want to share my treatment plan with my primary doctor to review.
• I understand that this is a cash only practice and I do not expect a refund for services already paid for.
• I agree to try my best and stay consistent with the treatment plan in order to achieve the best possible result for my health.
• I understand that if I have an emergency health issue of any nature, I should call my local emergency medical number, visit an urgent care, call my primary doctor, or if the situation is truly an emergency, call 911. 
• I agree to show up on time to my telehealth appointment and understand that visits are time-limited and there may be another member scheduled for their visit right after mine. 
• Lastly, I consent and understand that my anonymous data such as biomarker results or survey results might be used in an anonymous observational study to help offer the FDA and other regulating bodies evidence of the benefits of off label use of a non FDA approved medication. This is also known as 'real world evidence' which is in contrast to a sponsored clinical trial. 

Pharmacies we send our prescriptions to: We utilize an e-prescribing platform (DoseSpot) to send prescriptions to National Association of Boards of Pharmacy accredited and/or legitscript certified pharmacies. Presently, we send our prescriptions to TMC [200 Moore Dr, Nicholasville, KY 40356, Phone: (859) 887-0013]. We may in rare instances. and for commercially available medication, send an electronic prescription to CVS [1 CVS Drive, Woonsocket, RI, 02895, (800) 746-7287] a nationally recognized retail pharmacy which is NABP accredited but is not legitscript certified. In those rare instances, your medication may not be delivered to you depending on the location and service of the retail location and may require coordination for pickup. 

 

HIPAA Privacy Disclosure

HIPAA NOTICE OF PRIVACY PRACTICES 

This notice outlines your protected health information, how it may be used, and what your rights are. Please review carefully and ask any questions prior to signing.

 

Questions about this notice can be directed to HealthBrew Clinic:

HealBrew Clinic

C/o Dr. Alex Antoniou, MD

Mail: 700 K St. NW, Washington, DC. 

Email: support@healthbrewclinic.com

Tel: +1 240-232-3418

 

If you have a complaint and we could not resolve it, please know that 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/. 

Below is a standard HIPAA Notice. 

OUR PLEDGE REGARDING PROTECTED HEALTH INFORMATION:

We, HealthBrew understand that protected health information about you and your health is personal. We are committed to protecting health information about you. This Notice applies to all of the records of your care generated by HealthBrew, whether made by HealthBrew personnel or your personal doctor or other health care provider. This Notice will tell you about the standard ways in which we may use and disclose protected health information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of protected health information. The law requires us to:

• make sure that protected health information that identifies you is kept private
• notify you about how we protect protected health information about you
• explain how, when and why we use and disclose protected health information
• follow the terms of the Notice that is currently in effect.

We are required to follow the procedures in this Notice. We reserve the right to change the terms of this Notice and to make new notice provisions effective for all protected health information that we maintain by:

• posting the revised Notice in our office
• making copies of the revised Notice available upon request
• posting the revised Notice on our website.

HOW WE MAY USE AND DISCLOSE PROTECTED HEALTH INFORMATION ABOUT YOU

The following categories describe different ways that we use and disclose protected health information without your written authorization.

For Treatment: We may use protected health information about you to provide you with, coordinate or manage your medical treatment or services. We may disclose protected health information about you to doctors, nurses, technicians, medical students, or other personnel who are involved in taking care of you. HealthBrew staff may also share protected health information about you in order to coordinate the different things you need, such as prescriptions, lab work and x-rays. We also may disclose protected health information about you to people outside HealthBrew’s office who may be involved in your medical care. We may use and disclose protected health information to contact you as a reminder that you have an appointment for treatment or medical care at HealthBrew. We may use and disclose protected health information to tell you about or recommend possible treatment options or alternatives or health-related benefits or services.

For Payment for Services: We may use and disclose protected health information about you so that the treatment and services you receive at HealthBrew may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may need to give your health plan information about services you received at HealthBrew so your health plan will pay us or reimburse you for the service. We may also tell your health plan about the services you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.

For Health Care Operations: We may use and disclose protected health information about you for HealthBrew health care operations, such as our quality assessment and improvement activities, case management, coordination of care, business planning, customer services and other activities. These uses and disclosures are necessary to run the facility, reduce health care costs, and make sure that all of our patients receive quality care. We may also combine protected health information about many HealthBrew patients to decide what additional services HealthBrew should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, medical students, and other HealthBrew personnel for review and learning purposes. We may also combine the protected health information we have with protected health information from other health care facilities to compare how we are doing and see where we can make improvements in the care and services we offer. We may remove information that identifies you from this set of protected health information so others may use it to study healthcare and health care delivery without learning who the specific patients are. We may also contact you as part of a fundraising effort. Subject to applicable state law, in some limited situations the law allows or requires us to use or disclose your health information for purposes beyond treatment, payment, and operations. However, some of the disclosures set forth below may never occur at our facilities.

As Required By Law: We will disclose protected health information about you when required to do so by federal, state or local law.

Research: We may disclose your PHI to researchers when their research has been approved by an institutional review board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your information.

Health Risks: We may disclose protected health information about you to a government authority if we reasonably believe you are a victim of abuse, neglect, or domestic violence. We will only disclose this type of information to the extent required by law, if you agree to the disclosure, or if the disclosure is allowed by law and we believe it is necessary to prevent or lessen a serious and imminent threat to you or another person.

Judicial and Administrative Proceedings: If you are involved in a lawsuit or dispute, we may disclose your information in response to a court or administrative order. We may also disclose health information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made, either by us or the requesting party, to tell you about the request or to obtain an order protecting the information requested.

Business Associates: We may disclose information to business associates who perform services on our behalf (such as billing companies); however, we require them to appropriately safeguard your information. Public Health. As required by law, we may disclose your protected health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.

To Avert a Serious Threat to Health or Safety: We may use and disclose protected health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.

Health Oversight Activities: We may disclose health information to a health oversight agency for activities authorized by law. These activities include audits, investigations, and inspections, which may be necessary for licensure and for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Law Enforcement: We may release protected health information as required by law, or in response to an order or warrant of a court, a subpoena, or an administrative request. We may also disclose protected health information in response to a request related to identification or location of an individual, victims of crime, decedents, or a crime on the premises.

Organ and Tissue Donation: If you are an organ donor, we may release protected health information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank to facilitate organ or tissue donation and transplantation.

Special Government Functions: If you are a member of the armed forces, we may release protected health information about you if it relates to military and veterans’ activities. We may also release your protected health information for national security and intelligence purposes, protective services for the President, and medical suitability or determinations of the Department of State.

Coroners, Medical Examiners, and Funeral Directors: We may release protected health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also disclose protected health information to funeral directors consistent with applicable law to enable them to carry out their duties.

Correctional Institutions and Other Law Enforcement Custodial Situations: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release protected health information about you to the correctional institution or law enforcement official as necessary for your or another person’s health and safety.

Worker’s Compensation: We may disclose information as necessary to comply with laws relating to worker’s compensation or other similar programs established by law.

Food and Drug Administration: We may disclose to the FDA, or persons under the jurisdiction of the FDA, protected health information relative to adverse events with respect to drugs, foods, supplements, products and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.

YOU CAN OBJECT TO CERTAIN USES AND DISCLOSURES. Unless you object, or request that only a limited amount or type of information be shared, we may use or disclose protected health information about you in the following circumstances:

• We may share with a family member, relative, friend, or other person identified by you protected health information directly relevant to that person’s involvement in your care or payment for your care. We may also share information to notify these individuals of your location, general condition or death.
• We may share information with a public or private agency (such as the American Red Cross) for disaster relief purposes. Even if you object, we may still share this information if necessary for the emergency circumstances.

If you would like to object to use and disclosure of protected health information in these circumstances, please call or write to our contact person listed on page 1 of this Notice.

YOUR RIGHTS REGARDING PROTECTED HEALTH INFORMATION ABOUT YOU.

You have the following rights regarding protected health information we maintain about you:

Right to Inspect and Copy: You have the right to inspect and copy protected health information that may be used to make decisions about your care. Usually, this includes medical and billing records. To inspect and copy protected health information that may be used to make decisions about you, you must submit your request in writing to HealthBrew. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request, and we will respond to your request no later than 30 days after receiving it. There are certain situations in which we are not required to comply with your request. In these circumstances, we will respond to you in writing, stating why we will not grant your request and describe any rights you may have to request a review of our denial.

Right to Amend: If you feel that protected health information we have about you is incorrect or incomplete, you may ask us to amend or supplement the information. To request an amendment, your request must be made in writing and submitted to HealthBrew. In addition, you must provide a reason that supports your request. We will act on the/ your request for an amendment no later than 60 days after receiving the request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request, and will provide a written denial to you. In addition, we may deny your request if you ask us to amend information that:

• Was not created by us, unless the person or entity that created the information is no longer available to make the amendment
• Is not part of the protected health information kept by HealthBrew
• Is not part of the information which you would be permitted to inspect and copy, or
• We believe is accurate and complete.

Right to an Accounting of Disclosures: You have the right to request an "accounting of disclosures." This is a list of the disclosures we made of protected health information about you. To request this list or accounting of disclosures, you must submit your request in writing to HealthBrew. You may ask for disclosures made up to six years before your request (not including disclosures made before June 25, 2014). The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We are required to provide a listing of all disclosures except the following:

• For your treatment
• For billing and collection of payment for your treatment
• For health care operations
• Made to or request by you, or that you authorized
• Occurring as a byproduct of permitted use and disclosures
• For national security or intelligence purposes or to correctional institutions or law enforcement regarding inmates
• As part of a limited data set of information that does not contain information identifying you

Right to Request Restrictions: You have the right to request a restriction or limitation on the protected health information we use or disclose about you for treatment, payment or health care operations or to persons involved in your care. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment, the disclosure is to the Secretary of the Department of Health and Human Services, or the disclosure is for one of the purposes described on pages 4-5. To request restrictions, you must make your request in writing to HealthBrew.

Right to Request Confidential Communications: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing to HealthBrew. We will accommodate all reasonable requests.

Right to a Paper Copy of This Notice: You have the right to a paper copy of this Notice at any time by contacting HealthBrew (or by just printing it from your computer).

OTHER USES AND DISCLOSURES

We will obtain your written authorization before using or disclosing your protected health information for purposes other than those provide for above (or as otherwise permitted or required by law). You may revoke this authorization in writing at any time. Upon receipt of the written revocation, we will stop using or disclosing your information, except to the extent that we have already taken action in reliance on the authorization.

YOU MAY FILE A COMPLAINT ABOUT OUR PRIVACY PRACTICES

If you believe your privacy rights have been violated, you may file a complaint with HealthBrew, or file a written complaint with the Secretary of the Department of Health and Human Services. A complaint to the Secretary should be filed within 180 days of the occurrence of the complaint or violation. If you file a complaint, we will not take any action against you or change our treatment of you in any way.