Financial Responsibility

Patient Responsibility

I acknowledge and agree that I am responsible for all charges for services provided to me.

Medicaid or Medicare

Unfortunately, we are NOT enrolled in Medicaid or Medicare, and therefore we are unable to see patients with these benefits, even on a self-pay basis. It is your responsibility to disclose if you are receiving Medicaid or Medicare before receiving care from RutterMD. Failure to disclose your Medicaid or Medicare enrollment may result in discharge from our practice to protect both you and RutterMD from compliance issues under these programs.

Self-Pay Patients‍

As further described above, we do NOT participate in Medicaid or Medicare. Our services are 100% self-pay by our patients. By signing this form, you acknowledge that: 1) you do not have any health insurance, Medicaid, or Medicare; or 2) you will not use any insurance benefit for RutterMD services and acknowledge that RutterMD does not accept your health insurance.

‍In the event you have selected services for purchase from us on a self-pay basis, you have directed us to treat your purchase of these services as if you are an uninsured patient and you agree to be 100% responsible for full payment of the listed price of the services. If, though you have selected our “self-pay” option, you intend to submit a claim to your insurance company, please note that your insurance policy is a contract between you and your insurance company. It is your responsibility to know your benefits, and how they will apply to your benefit payments, and we take no responsibility to understand or be bound by the terms and conditions of such insurance. By signing this form, you are electing to purchase services that may or may not be covered by your insurance if you obtained those services from a different provider. There is no guarantee your insurance company will make any payment on the cost of the services you have purchased.

RutterMD has provided you with the charges, in advance, for the services you have requested. By signing, you agree to pay these charges in full as a self-pay patient, electing not to use an insurance policy benefit. You have been given a choice of different services, along with their costs. You have selected the services and are willing to accept full financial responsibility for payment. If you are a federal health program beneficiary, you agree that neither you, RutterMD, or any of our Providers will submit a claim for reimbursement to any federal or state healthcare program for the costs of the services and products provided to you through the services.

‍I have read the Agreement for Self-Payment of Services. I understand and agree to this Agreement.

Informed Consent for Telehealth Services

Informed Consent Telehealth

Informed Consent

Telehealth involves the use of electronic communications to enable healthcare providers at different locations to share individual patient medical information for the purpose of improving patient care. Telehealth services offered by RutterMD may also include chart review, remote prescribing, appointment scheduling, health information sharing, and non-clinical services, such as patient education. The information you provide may be used for diagnosis, therapy, follow-up and/or patient education, and may include any combination of the following: (1) health records and test results; (2) images and asynchronous communications and questionnaires; (3) live two-way audio and video; (4) interactive audio with store and forward; and (5) output data from medical devices and sound and video files.

The electronic communication systems we use will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

RutterMD providers are an addition to, and not a replacement for, your primary care physician. Responsibility for your overall medical care should remain with your local primary care doctor, if you have one, and we strongly encourage you to locate one if you do not.

Expected Benefits:

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Improved access to care by enabling you to remain in your home while the RutterMD provider consults and obtains test results at distant/other sites.

More efficient care evaluation and management.
Obtaining expertise of a specialist as appropriate.

Possible Risks

Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment and technologies.
In rare events, our provider may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled telehealth consult or a meeting with your local primary care doctor.
In very rare events, security protocols could fail, causing a breach of privacy of personal medical information.
In rare events, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors.

If you need to receive follow-up care, assistance in the event of an adverse reaction to the treatment, or in the event of an inability to communicate as a result of a technological or equipment failure, please contact RutterMD at support@ruttermd.com.

By checking the box associated with "Informed Consent", you acknowledge that you understand and agree with the following:

I have read this Informed Consent to receive services via telehealth carefully, and understand the risks and benefits of the use of telehealth in my medical care and treatment.
I hereby consent to receiving RutterMD’s services via telehealth technologies. I understand that RutterMD and its providers offer telehealth-based medical services, but that these services do not replace the relationship between me and my primary care doctor. I also understand it is up to the RutterMD provider to determine whether or not my specific clinical needs are appropriate for a telehealth encounter.
I understand that in some cases, my provider may be a nurse practitioner or physician assistant and not a physician.
I have been given an opportunity to select a provider from RutterMD prior to the consult, including a review of the provider’s credentials.
I understand that federal and state law requires health care providers to protect the privacy and the security of health information. I understand that RutterMD will take steps to make sure that my health information is not seen by anyone who should not see it. I understand that telehealth may involve electronic communication of my personal medical information to other health practitioners who may be located in other areas, including out of state.
I understand there is a risk of technical failures during the telehealth encounter beyond the control of RutterMD. I agree to hold harmless RutterMD for delays in evaluation or for information lost due to such technical failures.
I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment. I understand that I may suspend or terminate use of the telehealth services at any time for any reason or for no reason. I understand that if I am experiencing a medical emergency, that I will be directed to dial 9-1-1 immediately and that the RutterMD providers are not able to connect me directly to any local emergency services.
I understand that alternatives to telehealth consultation, such as in-person services are available to me, and in choosing to participate in a telehealth consultation, I understand that some parts of the services involving tests may be conducted by individuals at my location, or at a testing facility, at the direction of the RutterMD provider (e.g. labs or bloodwork).
I understand that I may expect the anticipated benefits from the use of telehealth in my care, but that no results can be guaranteed or assured.
I understand that I cannot obtain emergency care through the Services, and I should call 9-1-1 and seek immediate medical treatment if I am experiencing a medical emergency.
I understand that my healthcare information may be shared with other individuals for treatment, scheduling and billing purposes. Persons may be present during the consultation other than the RutterMD provider in order to operate the telehealth technologies. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/examination that are personally sensitive to me; (2) ask non-medical personnel to leave the telehealth examination; and/or (3) terminate the consultation at any time.
I understand that I will not be prescribed any narcotics for pain, nor is there any guarantee that I will be given a prescription at all.
I understand that if I participate in a consultation, that I have the right to request a copy of my medical records which will be provided to me at reasonable cost of preparation, shipping and delivery.

Patient Consent

I have read this document carefully, and understand the risks and benefits of the telehealth consultation and have had my questions regarding the procedure explained and I hereby give my informed consent to participate in a telehealth consultation under the terms described herein.

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By checking the Questionnaire Telehealth Consent agreement, I hereby state that I have read, understood, and agree to the terms of this document.

Notice of Privacy Practices

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.

This Notice of Privacy Practices (the “Notice”) describes how RutterMD may use and disclose your protected health information to carry out treatment, payment, or business operations and for other purposes that are permitted or required by law. “Protected health information” or “PHI” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical health or condition, and treatment.

This Notice also describes your rights to access and control your protected health information.

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION

Your protected health information may be used and disclosed by our health care providers, our staff, and, if necessary, others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to support our business operations, to obtain payment for your care, and any other use authorized or required by law.

TREATMENT

We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, your protected health information may be provided to any other health care provider with whom you have an existing treatment relationship to ensure the necessary information is accessible to diagnose or treat you.

HEALTH CARE OPERATIONS

We may use or disclose, as needed, your protected health information in order to support the business activities of this office. These activities include, but are not limited to, improving quality of care, providing information about treatment alternatives or other health-related benefits and services, development or maintaining and supporting computer systems, legal services, and conducting audits and compliance programs, including fraud, waste and abuse investigations. Under no circumstances will we sell or commercially market your information.

USES AND DISCLOSURES THAT DO NOT REQUIRE YOUR AUTHORIZATION

We may use or disclose your protected health information in the following situations without your authorization. These situations include the following uses and disclosures: as required by law; for public health purposes; for health care oversight purposes; for abuse or neglect reporting; pursuant to Food and Drug Administration requirements; in connection with legal proceedings; for law enforcement purposes; to coroners, funeral directors and organ donation agencies; for certain research purposes; for certain criminal activities; for certain military activity and national security purposes; for workers’ compensation reporting; relating to certain inmate reporting; and other required uses and disclosures. Under the law, we must make certain disclosures to you upon your request, and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of the Health Insurance Portability and Accountability Act (“HIPAA”). State laws may further restrict these disclosures.

USES AND DISCLOSURES THAT REQUIRE YOUR AUTHORIZATION

Other permitted and required uses and disclosures will be made only with your consent, authorization or opportunity to object unless permitted or required by law. In such cases, without your authorization, we shall not use or disclose your protected health information.

You have the right to receive an accounting of certain disclosures of your protected health information that we have made, paper or electronic, except for certain disclosures which were pursuant to an authorization, for purposes of treatment, payment, healthcare operations (unless the information is maintained in an electronic health record), or for certain other purposes.

You have the right to obtain a paper copy of this Notice, upon request, even if you have previously requested its receipt electronically by e-mail.

REVISIONS TO THIS NOTICE

We reserve the right to revise this Notice and to make the revised Notice effective for protected health information we already have about you as well as any information we receive in the future. You are entitled to a copy of the Notice currently in effect. Any significant changes to this Notice will be posted on the Services. You then have the right to object or withdraw as provided in this Notice.

BREACH OF HEALTH INFORMATION

We will notify you if a reportable breach of your unsecured protected health information is discovered.

Notification will be made to you no later than 60 days from the breach discovery and will include a brief description of how the breach occurred, the protected health information involved and contact information for you to ask questions.

COMPLAINTS

Complaints about this Notice or how we handle your protected health information should be directed to our HIPAA Privacy Officer. If you are not satisfied with the manner in which a complaint is handled you may submit a formal complaint to the 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.

We must follow the duties and privacy practices described in this Notice. If you have any questions about this Notice, please contact us at support@ruttermd.com.