PATIENT TERMS OF USE, PRIVACY, AGREEMENT AND CONSENT TO TREATMENT
BY CLICKING “AGREE,” YOU ACKNOWLEDGE THAT YOU HAVE READ, ACCEPTED, AND AGREED TO BE BOUND BY THIS PATIENT AGREEMENT AND CONSENT, TERMS OF USE AND PRIVACY. IF YOU DO NOT AGREE TO THIS PATIENT AGREEMENT AND CONSENT, TERMS OF USE AND PRIVACY, PLEASE DO NOT CLICK THE BUTTON.
Breezefast is a limited liability company that provides healthcare services using interactive video and technologies remotely, in which case both parties are not in same physical location. Breezefast contracts with physicians and allied medical professionals-Nurse Practitioners and Physician Assistant to provide medical services to individuals residing in Florida, California, New York, Washington DC. Please note the term “Doctors” refers to our team of physicians, Nurse Practitioner and Physician Assistant. Breezefast service is considered consultation services even if you continue to use the services for additional acute cases. You should seek emergency help or follow-up care when recommended by any of our providers, continue to consult with your primary care providers as recommended. This service does not replace your continued relationship with your primary care provider.
Telehealth involves the delivery of healthcare services using electronic communications, information technology or other means between a medical provider and a patient who are not in the same physical location. Telehealth may be used for diagnosis, treatment, follow-up and/or patient education, and may include, but is not limited to, one or more of the following: Electronic transmission of medical records, photo images, personal health information or other data between a patient and a medical provider. Interactions between a patient and medical provider via audio, video and/or data communications.
Breezefast will communicate with patients using audio, video, text communication. The use of telehealth and other technology by our medical provider may have the following possible benefits: -Ease and accessibility to medical care and treatment for acute conditions and some chronic conditions. -Convenient interaction with medical professional without the necessity of an in-office appointment. Possible Risks: Just like in any case, benefits of our services are improved access to healthcare and convenience. However, as with any health service, there are potential risks associated with the use of telehealth which includes: -Information given may be insufficient for the medical professional to make accurate medical plan, treatment. –
Our medical professionals may not be able to provide medical treatment for your particular condition and you may be asked to seek alternative healthcare or emergency care services. – lack of access to all of your health records may result in adverse drug interactions or other errors. -Technology failure may impact our medical professional’s ability to correctly diagnose or treat your medical condition. -The inability to obtain vital signs, or in-person assessment may prevent our medical professional from providing a diagnosis or treatment or from identifying the need for emergency medical care or treatment for you. – At Breezefast we incorporate strong security protocols to protect the confidentiality of your health information, in some instances, security protocols can fail, causing a breach of confidentiality. -Your condition may not be cured or improved. There are potential risks to the use of telehealth and other technology, including but not limited to the risks described in this Agreement. You have the right to withdraw your consent to the use of telehealth and technology in the course of your care at any time, which you may exercise by providing written notice to Breezefast LLC 4532 W. Kennedy Blvd, Suite 175, Tampa, FL 33609. Any withdrawal of your consent will be effective upon receipt of the written notice described above, except that such withdrawal will not have any effect on any action taken by Breezefast. By accepting this consent, you acknowledge that you understand and agree with the following:
• You understand that it is your duty to provide Breezefast and your medical professional truthful, accurate and complete information, including all relevant information regarding care that you may have received or may be receiving from healthcare providers other than Breezefast.
• Our medical professionals may share your health records with other health care providers for purposes relating to the provision, coordination or management of your healthcare so that we can meet your healthcare needs. This may include information relating to substance abuse, mental health, communicable diseases and other health conditions, subject to our terms.
• We may determine that our clinical services are not appropriate for some or all of your treatment needs and may elect not to provide clinical services to you through the Site.
• You acknowledge that some photographic or other images you submit to Breezefast via the Service or otherwise, and that will be shared with healthcare professionals may include portions of all of your breast or genitalia, and you hereby agree to the receipt of such images by our medical professionals solely for the purposes of providing you medical care and treatment. You represent that (a) you have read this Agreement carefully, (b) you understand the risks and benefits of the use of telehealth and other technology, including the Service, in the medical care and treatment provided to you by our medical professionals and (c) you have the legal capacity and authority to provide this consent for yourself.
Electronic Transmission When you use any Breezefast Service, or send e-mails, text messages, and other communications from your desktop or mobile device to us, you are communicating with us electronically. You consent to receive communications from us electronically. You agree that (a) all agreements and consents can be signed electronically and (b) all notices, disclosures, and other communications that we provide to you electronically satisfy any legal requirement that such notices and other communications be in writing.
Breezefast provides you with access to some aspects of your medical records which may include diagnosis, labs, medications and other health data gathered by Breezefast and information provided by you. Payment Terms. Breezefast is a concierge service which means that patients are responsible for payment of service provided, we do not bill third party such as insurance companies. You have the option of one-time payment in which a single service is provided or you may choose a monthly subscription that gives you unlimited access to a medical professional in a month, but note that this service still does not replace establishing a primary care provider relationship. We will only manage your acute symptoms and some intermittent chronic symptoms.
Breezefast also offers company sponsored program for employees and group plans. If you choose the monthly membership subscription, we may ask you to supply additional information relevant to your purchase, including, without limitation, your credit card number, the expiration date of your credit card and your billing address. You represent and warrant that you have the legal right to use all payment method information given. When you initiate a purchase, you authorize us to provide your payment Information to our third-party payment processors so we can complete your purchase and charge your payment method for the service you have selected. By agreeing to this Agreement and selecting monthly membership, you acknowledge that your membership has recurring payment features and you accept responsibility for all recurring payment obligations prior to cancellation of your membership subscription by you or Breezefast. Your membership subscription continues until cancelled by you or we terminate your subscription in accordance with this Agreement. In the event that your credit card expires, and our third-party payment processors are unable to process your payment, you may receive notice for you to provide an alternative payment method. You will not be able to receive any service unless you pay in full for the specific membership type you selected. Also note that our service fee is subject to change. You may cancel your monthly membership plan at any time. You may still use our service until end of the already paid billing month. To cancel your service, please send us an email at info@breezefast.com
Breezefast reserves the right to modify these Terms of Use at any time, effective upon posting. Any use of this website after such changes will be deemed an acceptance of those changes. You agree to review the Terms of Use each time you access this website so that you may be aware of any changes to these Terms Termination We may terminate your membership subscription, including your access to service, and this Agreement at any time, in our sole discretion. Terms of use You agree to protect the confidentiality of your user ID and password, and not to share or disclose your user ID or password to any third party. You agree that you are fully responsible for all activity occurring under your user ID. Your access to the Site may be revoked by Breezefast at any time with or without cause. You may not violate or attempting to violate the security of the Site, including, without limitation, (a) accessing data not intended for such user or logging onto a server or an account which the user is not authorized to access; or (b) attempting to probe, scan or test the vulnerability of a system or network or to breach security or authentication measures without proper authorization; or (c) accessing or using the Site or any portion thereof without authorization, in violation of these Terms of Use or in violation of applicable law. Breezefast service is available to adults 18 years and older only. Breezefast will not provide service to anyone younger than 18 even if adult consent is provided. Limitation of Liability.
IN NO EVENT SHALL BREEZEFAST BE LIABLE TO YOU OR ANY OTHER PERSON OR ENTITY FOR ANY DAMAGES (INCLUDING, WITHOUT LIMITATION, INCIDENTAL AND CONSEQUENTIAL DAMAGES, PERSONAL INJURY OR WRONGFUL DEATH, LOST PROFITS, OR DAMAGES RESULTING FROM LOST OR CORRUPTED DATA OR BUSINESS INTERRUPTION) RESULTING FROM THE USE OF OR INABILITY TO USE ANY TECHNOLOGY. BREEZEFAST SHALL NOT BE LIABLE FOR ANY PERSONAL INJURY, INCLUDING DEATH, CAUSED BY YOUR USE, MISUSE OR INABILITY TO USE OUR SERVICE.YOU AGREE TO YOUR WAIVER OF ANY RIGHT TO PARTICIPATE IN A CLASS ACTION SUIT AGAINST BREEZEFAST FOR ANY LOSSES OR DAMAGES RESULTING FROM YOUR USE OF OUR SERVICES. TO THE EXTENT ANY ASPECTS OF THE FOREGOING LIMITATIONS OF LIABILITY ARE NOT ENFORCEABLE, THE MAXIMUM LIABILITY OF BREEZEFAST TO YOU WITH RESPECT TO YOUR USE OF THIS SITE IS $1,000 (ONE THOUSAND DOLLARS)..
Binding Arbitration, Dispute Resolution/ Class Waiver. Breezefast will try work with you in good faith to resolve any issue you have with our medical professionals, controversies and claims related to this Agreement, any medical care or treatment provided by our medical professionals including any allegations of medical malpractice if you bring that issue to our attention by writing to Breezefast LLC 4532 W. Kennedy Blvd, Suite 175, Tampa, FL 33609 or email to info@breezefast.com. In the event we cannot resolve a dispute between us, including any allegations of medical malpractice, shall be finally and exclusively resolved by binding arbitration as described in this Section, which may be initiated by either party by sending a written notice requesting arbitration to the other. YOU
EXPRESSLY AGREES THAT ANY CLAIM, INCLUDING ANY CLAIM RELATING TO THE APPLICABILITY, ENFORCEABILITY OR VALIDITY OF ANY PROVISION OF THIS AGREEMENT (COLLECTIVELY “DISPUTES”), SHALL BE RESOLVED IN CONFIDENTIAL BINDING ARBITRATION CONDUCTED BEFORE ONE COMMERCIAL ARBITRATOR FROM THE AMERICAN ARBITRATION ASSOCIATION (“AAA”), RATHER THAN IN A COURT, AS DESCRIBED HEREIN. THE ARBITRATION WILL BE GOVERNED BY THE AAA’S COMMERCIAL ARBITRATION RULES AND, IF THE ARBITRATOR DEEMS THEM APPLICABLE, THE SUPPLEMENTARY PROCEDURES FOR CONSUMER RELATED DISPUTES (COLLECTIVELY “RULES AND PROCEDURES”). YOU ACKNOWLEDGE THAT YOU ARE VOLUNTARILY AND KNOWINGLY FORFEITING YOUR RIGHT TO A TRIAL BY JURY AND TO OTHERWISE PROCEED IN A LAWSUIT IN STATE OR FEDERAL COURT.
Payment of arbitration costs will be governed by the AAA’s fee schedule, unless you are able to show that your portion will be prohibitive as compared to litigation costs, in which case Breezefast will pay as much of your arbitration costs as the arbitrator deems necessary to prevent the arbitration from being cost-prohibitive as compared to litigation costs. Breezefast also reserves the right in its sole and exclusive discretion to assume responsibility for all arbitration costs imposed by the AAA. Each party agrees to pay its own attorneys’ fees and expenses unless there is a governing statutory provision that requires the prevailing party to be paid attorneys’ fees and expenses.The arbitration shall be conducted in Tampa, Florida, unless the parties agree otherwise in writing. The arbitrator’s award shall be final and binding on all parties and may be entered as a judgment in any court of competent jurisdiction. For more information on AAA, its Rules and Procedures, and how to file an arbitration claim, you may call AAA at 800-778-7879 or visit the AAA website at www.adr.org. All Disputes shall be resolved by binding confidential arbitration on an individual basis. You expressly agree that no other Disputes shall be consolidated or joined with your Dispute, whether through class arbitration proceedings or otherwise.
THE PARTIES AGREE THAT THERE IS NO RIGHT OR AUTHORITY FOR ANY DISPUTE TO BE ARBITRATED ON A CLASS-ACTION BASIS OR TO UTILIZE CLASS ACTION PROCEDURES, THERE IS NO RIGHT OR AUTHORITY FOR ANY DISPUTE TO BE BROUGHT IN A PURPORTED REPRESENTATIVE CAPACITY OR AS A PRIVATE ATTORNEY GENERAL, AND NO ARBITRATION SHALL BE JOINED WITH ANY OTHER ARBITRATION.
Force Majeure Breezefast will not be deemed to be in breach of these terms or liable for any breach of these terms or our privacy policy due to any event or occurrence beyond our reasonable control, including without limitation, acts of God, terrorism, electrical shortages, pandemic, war, invasion, failures of any public networks, earthquakes or floods, civil disorder, strikes, fire or other disaster. PATIENT AUTHORIZATION FOR USE AND DISCLOSURE OF
INFORMATION BY SIGNING, YOU ACKNOWLEDGE THAT YOU HAVE READ, ACCEPTED, AND AGREED TO BE BOUND BY THIS PATIENT AUTHORIZATION. YOU HEREBY GRANT AGENCY AUTHORITY TO ANY PARTY WHO SIGNS ON YOUR BEHALF. IN THIS AUTHORIZATION, THE TERMS “I”, “MY” AND “YOU” REFER TO THE PERSON WHO IS CREATING A PATIENT ACCOUNT, Information Covered by this Authorization: The information and data covered by this authorization includes all information or data that you submit to Breezefast or is collected on Breezefast behalf in connection with your treatment by Breezefast, including
(1) personally identifying information such as your name and contact data such as your e-mail address, phone number, and billing and physical addresses;
(2) your login and password; (3) demographic data (such as your gender, date of birth and zip code); (4) your communications with Breezefast medical professionals and employees; (5) any information you provide when you contact or communicate with Breezefast; (6) payment information; (7) health and medical data (such as previous doctors or other healthcare providers you visited, your reason for visiting a healthcare provider, date of visit, medical history and condition, medications, images or videos and other medical and health information and data you share with Breezefast or that is collected on Breezefast’s behalf. I acknowledge and agree that some of the uses and disclosures described in this authorization may not require a patient authorization under HIPAA and may be performed by Breezefast even if I do not agree to this authorization, and any such uses and disclosures will be governed by Breezefast Notice of Privacy Policy and Terms of Use. I understand that this Authorization will remain in effect from the date of this Authorization until the date that I provide written notice to Breezefast that I am terminating this Authorization. Privacy Act Breezefast is a Telehealth company that provides medical care online, and we understand that information about you and your health is personal. We strive to maintain the confidentiality of your health information. We continuously seek to safeguard that information through administrative, physical and technical means, and otherwise abide by applicable federal and state guidelines. Breezefast a medical provider and a “covered entity” for purposes of the Health Insurance Portability and Accountability Act of 1996, Public Law 104-191 and its related regulations and amendments from time to time (collectively, “HIPAA”).
Breezefast is permitted to use and disclose “protected health information” (“PHI”) in certain ways without obtaining any patient consent or authorization, but must obtain patient authorization for certain uses and disclosures as required by HIPAA. What information do we collect-(1) personally identifying information such as your name and contact data such as your e-mail address, phone number, and billing and physical addresses; (2) your login and password; (3) demographic data (such as your gender, date of birth and zip code); (4) your communications with Breezefast providers and employees; (5) any information you provide when you contact or communicate with Breezefast such as image, documents, contact us or make customer service request (6) payment information; (7) health and medical data (such as previous doctors or other healthcare providers you visited, your reason for visiting a healthcare provider, date of visit, medical history and condition, medications, images or videos and other medical and health information and data you share with Breezefast or that is collected on Breezefast’s behalf) (collectively, “Covered Information”).
Breezefast has partnered with Practice Fusion and Updox a cloud-based electronic health record and practice management solutions. Offering healthcare solution which include electronic health record, practice management and patient health record software, care coordination and clinical data transmission services, and health outcomes research solutions. Information shared with Breezefast is transferred into our third-party partner Practice Fusion platform(www.practicefusion.com) to provide a secure, HIPAA compliant electronic medical record utilization; integrated with Updox to provide secure HIPAA compliant video/sms interaction. Click here to read more about our partners privacy policy. Breezefast discloses to Practice Fusion and Updox,and uses certain patient information you provide to Breezefast in certain ways that may require patient authorization under HIPAA. By signing, you are providing written authorization for Breezefast and our third-party partner to use and disclose your information as described in this authorization. Such information may be used for the purpose of Providing secured service, communicating with me, sending me notifications, text, video communication, responding to my requests and needs. We use and disclose your health information for the normal business activities that the law sees as falling in the categories of treatment, payment and healthcare operations. Some ways that your information may be used are
(1)Treatment – This record may include your test results, diagnoses, medications, your response to medications or other therapies, and information we learn about your medical condition through the online Services. We may share this information so that other medical professional, including laboratories, imaging center can help meet your healthcare needs. (2)Payment – We document the services in the event that another third party need to pay us or in the event that you need your medical insurance to cover services such as imaging, labwork or cover your prescription. (3)Health care Operations – Health information is used to improve the services we provide, to train staff, for business management, quality assessment and improvement, and for customer service. We may also use your health information to: Comply with federal, state or local laws that require disclosure, assist in public health activities such as tracking diseases, Respond to law enforcement officials or to judicial orders, subpoenas or other process, Avert a serious threat to health or safety. We may also use or disclose your personal or health information for operational purposes. All other uses and disclosures, not previously described, may only be done with your written authorization. We will also obtain your authorization before we use or disclose your health information for marketing purposes. You may revoke your authorization at any time; however, this will not affect prior uses and disclosures. I acknowledge and agree that some of the uses and disclosures described in this authorization may not require a patient authorization under HIPAA and may be performed by Breezefast even if I do not agree to this authorization, and any such uses and disclosures will be governed by Breezefast’s Notice of Privacy Practices and Terms of Use. We are required by law to: Maintain the confidentiality of your medical information in accordance with applicable federal and/or state law; Comply with the terms of this notice, including any amendments; and Give you this notice of our legal duties and privacy practices with respect to medical information we maintain about you. We reserve the right to change the terms of this notice at any time. We also reserve the right to make the changes apply to your medical information we already have. Before we make a material change to this notice, we will promptly post a new notice in a clear and prominent area and on our website. You can also request a copy of the new notice by contacting our support staff. To ensure that your medical records are readily accessible to you, Breezefast provides you with access to certain components of your medical records through the Platform, including lab and treatment records. If you have any question about this privacy act, please email us at info@breezefast.com
BY CLICKING “AGREE,” YOU ACKNOWLEDGE THAT YOU HAVE READ, ACCEPTED, AND AGREED TO BE BOUND BY THIS PATIENT AGREEMENT, TERMS OF USE AND PRIVACY, AND CONSENT TO TREATMENT. BY SIGNING THIS FORM, YOU VOLUNTARILY CONSENT TO TREATMENT AND OTHER SERVICES DEEMED NECESSARY AND BENEFICIAL BY BREEZEFAST LLC, IT’S MEDICAL PROVIDERS, AND STAFF. I UNDERSTAND THAT NO GUARANTEE HAS BEEN MADE TO ME ABOUT THE OUTCOME OF MY TREATMENT AND I AM RESPONSIBLE FOR ANY ASSOCIATED CHARGES FOR THE SERVICES PROVIDED.
