Consent | Carda Health

Consent to Treat/Medical Records Release

Welcome to Carda Health!

To ensure we give you the best possible experience, we need to quickly collect some information from you. Please fill the following form out so that we can start planning your care.

If you have any questions please call us at (866)-932-5104. We are always on standby and happy to help.

This form will take 2-5 minutes to complete.

Medical Records Release Consent

I authorize the release of the items below (if applicable). I understand these records will only be used to aid in my treatment, and will not be released to any person or agency without my authorization:

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Consent to Participate

1. Purpose and Explanation of Procedure

The purpose of this consent is to inform you of the following: 1. How Carda Health and the treating Exercise Physiologist will use and disclose the information you share, 2. What other entities Carda Health might share information with, and 3. the risks associated with this telerehabilitation (Telerehab) encounter.

In order to improve my physical capacity and generally aid in my medical treatment for heart disease, I hereby consent to enter a virtual cardiac rehabilitation program that will include telemedicine visits, cardiovascular monitoring, physical exercise, dietary counseling, smoking cessation, stress reduction, and health education activities. The levels of exercise that I will perform will be based on the condition of my heart and circulation as determined by my care team. Professionally trained clinical personnel will provide leadership to direct my activities and may monitor my heart rate and blood pressure to be certain that I am exercising at the prescribed level. I understand that I am expected to attend every session and to follow staff instructions with regard to any medications that may have been prescribed, exercise, diet, stress management, and smoking cessation.

In the course of my participation in exercise, I will be asked to complete the activities unless such symptoms as fatigue, shortness of breath, chest discomfort, or similar occurrences appear. At that point, I have been advised that it is my complete right to stop exercise and that it is my obligation to inform the program personnel of my symptoms. I recognize and hereby state that I have been advised that I should immediately upon experiencing any such symptoms inform the program personnel of my symptoms. I understand that during the performance of in home exercise, a trained observer will periodically monitor my performance and monitor my blood pressure and heart rate, or make other observations for the purpose of monitoring my progress and/or condition. I also understand that the observer may reduce or stop my exercise program when findings indicate that this should be done for my safety and benefit.

2. Risks

It is my understanding that there exists the possibility during exercise of adverse changes including abnormal blood pressure; fainting; disorders of heart rhythm; and very rare instances of heart attack, stroke, or even death. Every effort will be made to minimize these occurrences through risk stratification, proper staff assessment of my condition before each exercise session, staff supervision during exercise, and my own careful control of exercise effort.

I understand and accept that Telerehab communication has associated risks as compared with in-person healthcare consultation. I understand there are limitations in completing a physical examination for a clinician; it may be more difficult for a clinician to manage some of my complaints or urgent problems, in which case I may be provided with information on how to seek urgent care. I also accept that there is increased risk of miscommunication with my healthcare provider, there is increased risk of interception of this communication, there are more uncertainties related to my privacy. I understand that if I become uncomfortable with any of these limitations of Telerehab, that I have the right to terminate the session at any time. Further, I understand that Telerehab is not the same as in-person healthcare services and if the exercise therapist feels that I would be a better candidate for in-person sessions that I may be requested by my clinician to attend such sessions at an appropriate location and that that is my choice. I understand that I will be provided with remote monitoring devices as part of a Remote Patient Monitoring program and that I am the only person who should be using the remote monitoring device(s) as instructed. I will not use the device(s) for reasons other than my own personal health monitoring. I am aware that my readings will be transmitted from RPM device(s) to a software platform in a safe and secure manner.

3. Benefits to Be Expected

I understand that this medical treatment may or may not benefit my health status or physical fitness. Generally, participation will help determine what recreational and occupational activities I can safely and comfortably perform at home or on my own. Many individuals in such programs also show improvements in their capacity for physical work. For those who are overweight and able to follow the physician's and dietitian's recommended dietary plan, this program may also aid in achieving appropriate weight reduction and control.

4. Confidentiality and Use of Information

I understand that Carda Health may collect, use and disclose my personal information and my personal health information for purposes of:

I authorize my TeleRehab Provider and its authorized agents to use or disclose my personal information and my personal health information to any other parties involved in my healthcare as reasonably required. Such parties may include a physician, another healthcare provider, an additional member of Carda Health’s treatment team, relevant funders or payors, referral sources or my employer if it relates to the demands of my job, my functional ability or my ability to return to work.

I have been informed that the information obtained from this rehabilitation program will be treated as privileged and confidential and will consequently not be released or revealed to any person without my express written consent. I do, however, agree to the use of any information for research and statistical purposes as long as it does not identify my person or provide facts that could lead to my identification.

I agree that Carda Health may use my email address and other contact information as a means of providing me information regarding my healthcare, including Telerehab, exercise progressions, appointment bookings and account notifications.

5. Acknowledgement

I acknowledge that I have read this page in its entirety. I further understand that there are remote risks other than those previously described that may be associated with this program. Despite the fact that a complete accounting of all remote risks is not entirely possible, I am satisfied with the review of these risks that was provided to me, and it is still my desire to participate.

Agreement Of Financial Responsibility

Thank you for choosing Cupid Medical PSC/Cupid Medical of California as your healthcare provider. We are committed to providing quality care and service to all of our patients. The following is a statement of our financial policy, which we require that you read and agree to prior to any treatment.

A photo of insurance card(s) is required for all patients. We will ask for a copy of your insurance card for our records. Proof of insurance is required for all patients that are not paying cash at time of service. Providing a copy of your insurance card(s) does not confirm that your coverage is effective or that the services rendered will be covered by your insurance company.

We require all patients to pay their copay at time of service. This arrangement is part of your contract with your insurance company. We accept credit cards as a payment option.

It is your responsibility to know your insurance benefits, including whether we are a contracted provider with your insurance company, your covered benefits and any exclusions in your insurance policy, and any pre-authorization requirements of your insurance company. Please contact your insurance company with any questions about your benefits and coverage.

We will attempt to confirm your insurance coverage prior to your treatment. It is your responsibility to provide current and accurate insurance information, including any updates and changes in coverage. Should you fail to provide this information, you will be financially responsible.

We participate in most insurance plans. If we have a contract with your insurance company we will bill your insurance company first, and then bill you for any amount determined to be your responsibility, less what was collected at time of service (copay amount). This process generally takes 45-60 days from the time the claim is received by the insurance company.

If we do not contract with your insurance company, we will, as a courtesy, file a claim with your insurance carrier. Please understand some insurance coverages have out-of-network benefits that may be subject to deductibles and higher out of pocket responsibility from you. If you receive services that are part of an out-of-network benefit, your portion of financial responsibility may be higher than if you used an in-network provider. Once your insurance processes the claim, we will send you a statement for your balance due. Payment is due upon receipt of the statement.

Patients with an outstanding balance of 60 days or more overdue must make payment arrangements prior to scheduling future appointments. Chronic nonpayment may result in referral of balance to an outside collection agency and termination of services.

I have read the financial policies contained above, and my signature below serves as acknowledgement of a clear understanding of my financial responsibility. I understand that if my insurance company denies coverage and/or payment for services provided to me, I assume financial responsibility and will pay all such charges in full.

By entering my name below I acknowledge I have read and agree to the Terms of Service, Privacy Policy, and Notice of Privacy Practices.

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