PWNHealth Informed Content

PWNHealth

Informed Consent

Effective Date: March 19, 2020

 

General Informed Consent

(Including Telehealth Consent)

 

I agree to receive the services provided by PWNHealth (the administrative services provider of the professional entities), PWN Remote Care Services, PW Medical Professional and certain other affiliated professional entities (collectively, “PWNHealth”, “we” or “us”) relating to ordering a WatchPAT ONE Sleep Apnea test (“Test”), including, without limitation, evaluation of the Test request, ordering of the Test (if appropriate), receipt and evaluation of Test results (“Results”), physician consultations via telemedicine (“Consults”), any customer support or counseling and any other related services provided by PWNHealth or its service providers and partners (the “PWN Services”). All clinical PWN Services, including PWN Services provided by physicians, will be provided through PWN Remote Care Services, PW Medical Professional or their contractually affiliated professional entities.

 

I acknowledge and agree to the following:

  • I am the individual who will provide the sample for the Test(s) that I am ordering.
  • I am at least eighteen (18) years of age.
  • I have read and understand the information provided about the Test(s) that I am ordering at www.lunella.com.
  • The information I have provided in connection with the PWN Services is correct to the best of my knowledge. I will not hold PWNHealth or its health care providers responsible for any errors or omissions that I may have made in providing such information.
  • My health information and Results may be shared with other PWNHealth health care providers, including physicians, and counselors for purposes of providing care to me.
  • The PWN Services do not constitute treatment or diagnosis of any condition, disease or illness.
  • While PWNHealth, Lunella and Itamar Medical implement safeguards to avoid errors, as with all devices and tests, there is a chance of a false positive or false negative Result.
  • I understand that PWNHealth is not responsible for any of the services or devices provided by Lunella or Itamar Medical.
  • I am responsible for checking my email for Results notification and logging on to my account to view my Results when available.
  • I will not make medical decisions without consulting a healthcare provider, disregard medical advice from my healthcare provider or delay seeking such advice based on information as a result of the use of the PWN Services.

 

I understand that PWN Services, including Consults, are delivered by health care providers who are not in the same physical location as I am using electronic communications, information technology or other means, including the electronic transmission of personal health information. I also understand that:

  • I may be required to complete a pre-test telemedicine Consult with a PWNHealth physician. I may also elect to receive a pre-test Consult with a PWNHealth physician. I may also speak with the PWNHealth clinical team, including a physician after I have received my Results and at any time during the process.
  • A PWNHealth physician will determine whether or not the Test and PWN Services are appropriate for me based on the information provided by me, including information provided during a pre-test Consult, if applicable.
  • I understand that, after the Test is performed, my Results will be available in my account. If my Results are abnormal PWNHealth's Care Coordination Team will attempt to call me to discuss the Results, provide educational information, and discuss plans for managing my health moving forward, including to advise me to reach out to a physician, such as my primary care or personal physician, to obtain an interpretation of the Results and for care, diagnosis, and medical treatment. If I do not answer the phone, PWNHealth’s Care Coordination Team may leave me a voicemail but will not include my test Results in any voicemail message. If I receive my Results and have not connected with PWNHealth’s Care Coordination Team, I understand that I should not delay following up with my personal physician. I understand that I may contact PWNHealth’s Care Coordination Team at any time with questions.
  • I am responsible for forwarding any Results to my primary care or other personal physician and for initiating follow up with such physician for care, diagnosis, medical treatment or to obtain an interpretation of the Results.
  • After receiving my Results, I understand that I may elect to request a consult with a Lunella or Itamar Medical physician for an additional fee.
  • I certify that (i) I am a resident of the United States and (ii) when I receive PWN Services, including throughout the duration of my Consult, I will be physically present in the state (or U.S. territory) of residence I provided or other state (or U.S. territory) of which I have notified PWNHealth.
  • The scope of services for the Consult will be at the sole discretion of the physician. The physician will not provide a diagnosis, treatment, or prescription. The physician will determine whether or not the PWN Services being rendered are appropriate for a telehealth encounter.
  • I have the right to withdraw my consent to the use of telehealth in the course of my care at any time by contacting the PWNHealth's Care Coordination Team by calling +1 (888) 514-7199.
  • Any video feed from the Consult will not be retained or recorded by PWNHealth.
  • My health and wellness information pertaining to telehealth services are governed by the PWNHealth Terms of Use and the PWNHealth Notice of Privacy Practices.
  • There are potential risks associated with the use of technology, including disruptions, loss of data and technical difficulties. I agree to hold PWNHealth harmless for information lost due to technical failures.
  • There are alternative services, such as visiting a primary care provider, an emergency room, or an urgent care facility; however, I chose to proceed with the PWN Services at this time.

 

I understand that if I have any questions before or after my Test, I can contact PWNHealth's Care Coordination Team by calling +1 (888) 514-7199.

 

I authorize PWNHealth to use the email address and phone number I provided in connection with my account at the time I purchased my Test(s) (or that I updated by contacting PWNHealth's Care Coordination Team as described below) to contact me in connection with the PWN Services, including follow-up after receiving the PWN Services. I am responsible for contacting PWNHealth's Care Coordination Team by calling +1 (888) 514-7199 to notify them of any changes to my mailing address, email address, phone number or other information that I provided in connection with the PWN Services.

 

I understand that if I have any questions before or after my Test, I can contact PWNHealth's Care Coordination Team by calling +1 (888) 514-7199.

 

I authorize PWNHealth to use the email address and phone number I provided in connection with my account at the time I purchased my Test(s) (or that I updated by contacting PWNHealth's Care Coordination Team as described below) to contact me in connection with the PWN Services, including follow-up after receiving the PWN Services. I am responsible for contacting PWNHealth's Care Coordination Team by calling +1 (888) 514-7199 to notify them of any changes to my mailing address, email address, phone number or other information that I provided in connection with the PWN Services.  

 

I understand that PWNHealth may contact me after my Consult or Results via email with a survey which may include questions regarding customer satisfaction and follow up care.  I understand that this email survey may refer to the Cologuard test. If I would prefer to receive the survey via another method of communication, I will contact the PWNHealth Care Coordination Team.    I understand that PWNHealth may contact me via phone or other communication based on my responses to the survey. 

 

I understand that testing is voluntary and that I may withdraw my consent to testing at any time prior to the completion of the Test(s) by contacting PWNHealth's Care Coordination Team by calling +1 (888) 514-7199.

 

I have read this Informed Consent carefully, and all my questions were answered to my satisfaction.  I hereby consent to participate in the PWN Services, including the performance of the Test(s) and the Consult, pursuant to the terms, conditions, standards, and requirements set forth herein, in the PWNHealth Terms of Use and PWNHealth Notice of Privacy Practices or as otherwise provided to me.

 

Data Authorization

 

I specifically authorize the transfer and release of my information as described herein and in the Notice of Privacy Practices available to me when seeking and purchasing the PWN Services, including my Test Results and other identifiable health information, submitted by me or about me in connection with the PWN Services, to, between and among myself and the following individuals, organizations and their representatives: (a) Lunella, Itamar Medical and their affiliates, their staff and agents; and (b) PWNHealth and its affiliates, and their staff, agents, and health care providers, including physicians, to facilitate and execute the PWN Services requested by me or performed with my consent (including receiving, evaluating and approving a laboratory test request; evaluating, processing and delivering the test value(s)/result(s)), and as required or permitted by law. 

 

I understand that I have a right to receive a copy of the above data disclosure authorization.  I have the right to refuse to agree to this authorization in which case my refusal may affect the PWN Services  provided to me.  When my information is used or disclosed pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer be protected by privacy laws.  I have the right to revoke this authorization in writing at any time, except that the revocation will not apply to any information already disclosed by the parties referenced in this authorization.  This authorization will expire ten (10) years from the date of signature.

 

My written revocation must be submitted to PWNHealth’s General Counsel at:

PWN Remote Care Services
c/o PWNHealth, LLC
Attn: General Counsel
123 West 18th Street, 8th Floor
New York, NY 10011