HIPAA Consent Agreement

HIPAA Authorization & Consent Agreement

Last Updated: 01/01/2025

‍

Provider Name & Address
Rebecca Martel Nurse Practitioner PLLC, doing business as “Certicare NP”
418 Broadway #4220, Albany, NY 12207, USA
Phone: (607) 301-3594 | Fax: (518) 413-8063 | Email: support@certicare.org

‍

1. Introduction

Certicare NP (“we,” “us,” or “our”) is committed to protecting your privacy in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and other applicable laws and regulations. This HIPAA Authorization & Consent Agreement (“Agreement”) describes how we may use and disclose your Protected Health Information (“PHI”) and your rights regarding that information.

‍

By clicking “I Agree” or otherwise indicating your acceptance of this Agreement during checkout or intake, you acknowledge that you have read, understood, and agree to the terms herein. If you do not agree, you will not be able to use our telehealth services.

‍

2. Description of PHI to Be Used or Disclosed

By agreeing to this document, you authorize Certicare NP to use or disclose your PHI, which may include:

• Personal Identifiers: Name, date of birth, address, contact information, or other identifying details.
• Health Information: Medical condition(s), symptoms, diagnoses, or related health information provided to us through our asynchronous telehealth services or forms.
• Documentation: Medical notes, return-to-work/school forms, and related materials we generate or maintain in connection with providing you telehealth services.

3. Purpose of Use or Disclosure

Your PHI may be used or disclosed for the following purposes:

1. Treatment: To provide telehealth consultations, medical notes, or other care-related services.
2. Payment: To process payments, verify insurance eligibility (if applicable), handle billing inquiries, and coordinate with payment processors.
3. Healthcare Operations: For quality assurance, compliance audits, training, and other internal operations necessary to maintain and improve our telehealth platform.
4. Verification Requests: In response to an authorized party (e.g., employer or educational institution) that provides the required identifying information (as outlined in our Terms & Conditions) to verify the authenticity of medical notes or other documentation we issue.
5. Legal Compliance: If required by law or in response to subpoenas, court orders, or other valid legal processes, in accordance with HIPAA.

4. Parties Authorized to Receive PHI

We may share your PHI with the following parties:

• Healthcare Providers or Facilities if referrals or coordination of care are necessary.
• Payment Processor(s) (e.g., Stripe) or billing service providers, strictly for payment-related purposes.
• Verification Requestors (e.g., employers, schools) with whom you authorize or who have legal authority to access such information, and who follow our verification process.
• Business Associates and other service providers who assist us in providing telehealth services, subject to Business Associate Agreements and HIPAA requirements.

5. Expiration of This Authorization

This Authorization will remain in effect until:

1. You choose to revoke it by contacting us in writing (see Section 6)

6. Right to Revoke

You may revoke this Authorization at any time by sending a written request to:

Certicare NP
Attn: Privacy Officer
418 Broadway #4220
Albany, NY 12207, USA
Email: support@certicare.org

Your revocation will be effective upon our receipt but will not apply to any uses or disclosures made in reliance on this Agreement before the revocation date. If you revoke this Authorization, you may no longer be able to use certain aspects of our telehealth services that rely on this consent.

‍

7. Potential for Redisclosure

Once disclosed pursuant to this Agreement, your PHI may be redisclosed by the recipient if they are not legally obligated to maintain its confidentiality. In such cases, your PHI may no longer be protected by HIPAA or other privacy laws.

‍

8. Voluntary Nature of Authorization

Your decision to authorize the use and disclosure of your PHI is voluntary. However, if you do not agree to these terms, we cannot provide our telehealth services to you. This Agreement does not restrict your ability to obtain medical care from other healthcare providers.

‍

9. Security of Your Information

We implement industry-standard administrative, technical, and physical safeguards to protect the confidentiality, integrity, and availability of your PHI. Despite these safeguards, no method of transmission over the internet or electronic storage is 100% secure, and we cannot guarantee absolute security.

‍

10. Acceptance of This Authorization

By clicking “I Agree” or otherwise indicating your acceptance of this Agreement, you:

1. Acknowledge that you have read and understood this HIPAA Authorization & Consent Agreement.
2. Consent to Certicare NP’s use and disclosure of your PHI as described above.
3. Understand that you have the right to revoke this Authorization at any time by submitting a written request.

11. Contact Information

If you have any questions or concerns regarding this Agreement, your privacy rights, or the handling of your PHI, please contact:

• Certicare NP
• Phone: (607) 301-3594
• Fax: (518) 413-8063
• Email: support@certicare.org
• Address: 418 Broadway #4220, Albany, NY 12207, USA

‍