PATIENT SERVICE AGREEMENT AND CONSENT FORM
Effective date: 6/1/2023
Reframe Health, Inc., a Delaware corporation d/b/a Frame Fertility, and Reframe Healthcare, LLC, and other entities that provide professional services under a partnership with Frame Fertility (each a “Practice”) (collectively referred to herein as “Frame Fertility,” “we,” “our,” or “us”) are honored to provide you with personalized support and care. The Practice is solely responsible for the delivery of medical and other licensed professional services you may receive. Frame Fertility provides management, administrative, and technology services to the Practices.
Although this document is long, it is very important that you understand it. When you sign this document, it will represent an agreement between you and Frame Fertility. Federal and state law requires that we provide to you certain information set forth in this document. A full copy of this Patient Service Agreement and Consent Form will be furnished for your records upon request. If you have any questions, please ask your provider or coach, or contact us at firstname.lastname@example.org.
Telehealth. You agree to receive telehealth services in the specialty for which you scheduled your services and coaching services via telehealth by unlicensed, but trained, coaches (the “Telehealth Services”). Telehealth involves the use of audio, video, or other electronic communications to interact with you, consult with your service provider, and/or review your medical information for the purpose of diagnosis, therapy, follow-up, coaching and/or education; telehealth may be provided as synchronous (in real time) or asynchronous (not in real time, such as by sending a chat or a photo and later receiving a response). During your telehealth consultation with Frame Fertility providers and coaches, details of your medical history and personal health information may be collected and such information may be disclosed and/or discussed with other health professionals involved in your care and treatment through the use of interactive video, audio, and telecommunications technology. The benefits of telehealth include having access to specialists and additional medical information and education without having to travel outside of your home or local health care community. A potential risk of telehealth is that because of your specific medical condition or due to technical problems, a face-to-face consultation may still be necessary after the telehealth appointment. You agree that your Frame Fertility provider shall determine whether or not the condition being diagnosed and/or treated is appropriate for a telehealth encounter. Additionally, while Frame Fertility shall comply with all administrative, physical and technical safeguards set forth in the Health Insurance Portability and Accountability Act of 1996 and its implementing regulations, in rare circumstances, security protocols could fail, causing a breach of patient privacy. Frame Fertility shall hold you harmless for any information lost due to technical failures. The alternative to receiving Telehealth Services is to not receive them. You understand the risks, benefits, and alternatives of receiving Telehealth Services. You may ask your provider any questions you may have regarding Telehealth Services. You may be asked to sign additional consents or provide additional information before receiving Telehealth Services if you reside in a state where additional documentation or additional information is required prior to receiving Telehealth Services.
Telehealth Services should not be used for a medical emergency; in a medical emergency, you should dial 911.
Team-Based/Interdisciplinary Approach to Care. Frame Fertility believes that the best care is provided when all members of your health care team work together and collaborate. Accordingly, and in furtherance of this model, all professionals and coaches involved in your care, including primary care providers, OB-GYN, and reproductive endocrinologists, may share information regarding your care and treatment in order to provide you with the best care possible for you, except when sharing this information is expressly prohibited by law.
Scheduling Services. All services can be scheduled by using Elation Health.
Payment Methods. You understand and agree that any payment for services shall be made prior to or at the time of service, except for the portion of the payment that may be (a) covered by your insurance plan; (b) included in the payment made to another service provider with which Frame Fertility partners; or (c) included in your membership. The payment amount will depend on how you access our services. Frame Fertility will advise you in advance of providing any services what your anticipated costs of receiving services will be. We accept payment in the form of a credit card, which you expressly authorize us to charge for the Telehealth Services and any other service you elect to receive from us that is not covered by your insurance, your membership (if any), or other payment received by Frame Fertility.
- Insurance. If you will be using insurance to cover some or all of the cost of your services, you should contact us ahead of your appointment to ensure that your insurance is accepted and provide a photo of your insurance card prior to the appointment via our website. You should be prepared to pay any copayments at the time of the appointment. If we are out-of-network for your insurance, you will be responsible for payment at the time of the services. You may submit an out-of-network claim to your insurer to receive reimbursement, if any is available under your benefit plan.
- Membership. Certain individuals may access the services through a membership model for which we charge a membership fee (the “Membership Fee”). Our current Membership Fee options are available on the Frame Fertility website and may be modified from time to time. If you elect to receive services through a membership model, you agree to pay the Membership Fee at the intervals indicated when you signed up for the membership with us. You also authorize us or our third-party contractor to charge the credit card you provided to us at the intervals you agreed to when you signed up for the membership unless you terminate this Patient Services Agreement and Consent Form (“Agreement”) prior to the date on which we would charge your card for the Membership Fee. You understand that we will automatically charge your credit card at such intervals.
Consent for Assignment of Insurance Benefits. To the extent we accept your insurance, you authorize the payment of insurance benefits payable directly to us, and you assign and transfer to us all right, title, and interest in the right to receive all benefits payable for the health care rendered that are provided for in any and all insurance policies and/or plans that will be applied to the amount charged for services rendered by your Frame Fertility provider.
Cancellation Policy. For any appointment that is scheduled in advance, excluding on-demand chat-based care interactions, you understand that your appointment must be canceled no less than twenty-four (24) hours in advance or you will be responsible for a $50 cancellation fee for the missed visit, unless your insurance prohibits us from billing you for missed visits.
Confidentiality and Compliance. We will take appropriate precautions to keep your health information confidential and not disclose it without your consent. You are also protected under the provisions of the federal Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and any other applicable federal and state laws related to the protection of patient information and how we will use and disclose your protected health information. Our Notice of Privacy Practices (“NPP”) discusses how we will use and disclose your protected health information; you have received a copy of our NPP available here. The most up-to-date NPP is posted on our website.
Consent to Call, Email, Text, and Application Messaging. You expressly consent to allow our agents and us to communicate with you by telephone call, email, text message, and/or other forms of unencrypted electronic messaging (“Electronic Messages”) using any telephone numbers or email addresses that you provide us or that we obtain lawfully, such as through caller ID. You expressly agree to receive prerecorded or automated Electronic Messages from us. You agree to receive these Electronic Messages from us even if your phone number is listed on the National Do Not Call Registry. You agree that you are the current owner of any telephone number you provide us. Wireless or data charges from your carrier may apply, and we are not responsible for these charges.
You understand that we do not require that you give your consent to receive automated Electronic Messages in order to receive services from us.
You understand that Electronic Messages sent by us may include, without limitation, appointment reminders, changes in previously scheduled appointments, actions to take in advance of appointments, follow-ups from appointments, information regarding insurance and billing, marketing material, and advice or education.
You understand the risks associated with communicating through Electronic Messages, including, without limitation, that Electronic Messages can easily be mis-addressed to or forwarded to unintended recipients, that Electronic Messages can be stored, that backup copies of Electronic Messages may exist even after the Electronic Messages are deleted, that Electronic Messages may not be secure and thus may be used or forwarded without your permission or knowledge, that Electronic Messages may be inspected by your telephone carrier, and that Electronic Messages may be used as evidence in court. You understand that we are not liable for any breaches of confidentiality caused by you or a third party.
You understand that Electronic Messages may be filed in your medical record.
You may opt out of automated Electronic Messages, including SMS and/or email, at any time. You may send your request via email to email@example.com. You acknowledge and agree to receive a final message confirming your choice to opt out. Unless you revoke your consent to communicate with us via Electronic Messages, your consent will last through the end of your relationship with us.
In exchange for the services provided by us, you release us from all claims, causes of action, lawsuits, damages, losses, liabilities, or other harms relating to any Electronic Messages you exchange with us. You release us from all claims, causes of action, or lawsuits based on any alleged violations of any laws, including the Telephone Consumer Protection Act, the Truth in Caller ID Act, the CAN-SPAM Act, the Fair Debt Collection Practices Act, the Fair Credit Reporting Act, HIPAA, any similar state and local acts or statutes, and any federal or state tort or consumer protection laws.
Recording. You acknowledge that telephone calls and video/visits to or from us may be monitored and recorded by Frame Fertility. You agree to this monitoring and recording.
Practitioners & Credentials. A list of Frame’s practitioners and their associated credentials can be found here: www.framefertility.com/practitioners-and-credentials.
Acknowledgments. You have read and understand the information provided above and understand and agree to the terms in this Agreement, including the services, payment methods, and cancellation policy. Any questions you had have been answered.
You also understand that, under HIPAA, you have certain rights to privacy regarding your health information. You have received, have read, and understand Frame Fertility’s NPP containing a complete description of the uses and disclosures of your health information. You understand that Frame Fertility has the right to change the NPP from time to time and that you may contact Frame Fertility at any time to obtain a current copy of the NPP.
Updates/Revisions. We may update this Agreement upon thirty (30) days’ notice to you. Notice and updates will be provided via our website at www.framefertility.com/patient-service-agreement.