Membership Level

You have selected the Dr. John’s Acute Family Healthcare $8.00 per Month (billed annually) membership level.

The price for membership is $96.00 per Year.

Enroll in Dr. John’s telehealth program and receive a $100 discount on Dr. John’s sleep apnea management services.

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Terms and Conditions
TELEMEDICINE

Dr. John’s Medical Solutions is a telehealth broker for Salus Telehealth, a doctor consultation service. You are entering into a doctor/patient relationship with physicians associated with Salus Telehealth. You acknowledge that doctors made available to you in this telehealth program are not a substitute for your Primary Care Physician (PCP). Telehealth doctors are responsible for all medical advice given. Medical advice is not meant to replace treatment and consultation with the Enrollee’s PCP.
This program should not be construed as an insurance policy.

GENERAL RELEASE

A. You agree that Dr. John’s Medical Solutions or Salus Telehealth will not be liable for any damages whatsoever, including direct, indirect, incidental, special, consequential or exemplary damages (even if we have been advised of the possibility of such damages), arising from, relating to or connected with:

  1. The use or inability to use our service
  2. The cost of replacement of any goods, services or information purchased or obtained as a result of any information obtained from or transactions entered into through or from our service,
  3. Disclosure of, unauthorized access to or alteration of your content
  4. Statements, conduct or omissions of any service providers or other third party on our service
  5. Actions or inactions of other users of our site or our service or any other third parties for any reason, or
  6. Any other matter arising from, relating to or connected with our service or these terms.

B. We will not be liable for any failure or delay in performing under these terms where such failure or delay is due to causes beyond our reasonable control, including natural catastrophes, governmental acts or omissions, laws or regulations, terrorism, labor strikes or difficulties, communications systems breakdowns, hardware or software failures, transportation stoppages or slowdowns or the inability to procure supplies or materials.
C. In no event will our aggregate liability to you or any third party in any matter arising from, relating to or connected with our service or these terms exceed the sum of one hundred ($1,000) dollars.
D. Some jurisdictions do not allow the exclusion of certain warranties or the limitation or exclusion of liability for incidental or consequential damages. Accordingly, some of the limitations of the foregoing sections may not apply to you.

TRANSMISSION OF MEDICAL INFORMATION

An Enrollee's medical information may be mailed, faxed or released over the telephone when authorized, along with any documents the Enrollee has supplied to Salus Telehealth.

INFORMED CONSENT FOR TELEMEDICINE SERVICES

Introduction
Telemedicine involves the use of electronic communications to enable health care providers at different locations to share individual patient medical information for the purpose of improving patient care. Providers may include primary care practitioners, specialists, and/or subspecialists. The information may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:

  • Patient medical records
  • Medical images
  • Live two-way audio and video
  • Output data from medical devices and sound and video files

Electronic systems used 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.
Expected Benefits

  • Improved access to medical care by enabling a patient to remain in his/her ophthalmologist’s office (or at a remote site) while the physician obtains test results and consults from healthcare practitioners at distant/other sites.
    P. O. BOX 945, BRENTWOOD, TN 37024-0945 * (615) 791-6247 * info@docjmd.com * www.docjmd.com
  • More efficient medical evaluation and management.
  • Obtaining expertise of a distant specialist.

Possible Risks
As with any medical procedure, there are potential risks associated with the use of telemedicine. These risks include,
but may not be limited to:

  •  In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow
    for appropriate medical decision making by the physician and consultant(s);
  • Delays in medical evaluation and treatment could occur due to deficiencies or failures of the
    equipment;
  • In very rare instances, security protocols could fail, causing a breach of privacy of personal medical
    information;
  • In rare cases, a lack of access to complete medical records may result in adverse drug interactions or
    allergic reactions or other judgment errors;

By enrolling is Dr. John’s Medical Solutions telehealth service, I understand the following:

  1.  I understand that the laws that protect privacy and the confidentiality of medical information also apply to
    telemedicine, and that no information obtained in the use of telemedicine, which identifies me, will be
    disclosed to researchers or other entities without my consent.
  2. I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the
    course of my care at any time, without affecting my right to future care or treatment.
  3. I understand that I have the right to inspect all information obtained and recorded in the course of a
    telemedicine interaction, and may receive copies of this information for a reasonable fee.
  4. I understand that a variety of alternative methods of medical care may be available to me, and that I may
    choose one or more of these at any time. My ophthalmologist has explained the alternatives to my
    satisfaction.
  5. I understand that telemedicine may involve electronic communication of my personal medical information to
    other medical practitioners who may be located in other areas, including out of state.
  6. I understand that it is my duty to inform my ophthalmologist of electronic interactions regarding my care that
    I may have with other healthcare providers.
  7. I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no
    results can be guaranteed or assured.

Patient Consent to The Use of Telemedicine
I have read and understand the information provided above regarding telemedicine, have discussed it with my
physician or such assistants as may be designated, and all of my questions have been answered to my satisfaction. I
hereby give my informed consent for the use of telemedicine in my medical care.
PRESCRIPTIONS AND REFILL POLICY
Our Doctors provide a consultation as cross-coverage for a Member’s primary care doctor and, at their discretion, and
may write a prescription for a non-narcotic, non-DEA-controlled, or non-lifestyle
modification substance where allowed by law and when sufficient medical history is available.
The listing of controlled medications: http://www.deadiversion.usdoj.gov/schedules/orangebook/c_cs_alpha.pdf.
Please note that certain states have specific guidelines prohibiting telehealth doctors from prescribing
medications. For those states, only doctor consultations may be provided.
Generally, prescriptions include:

  •  Thirty day (30) limits on first prescription or refill.
  • Fifteen-day (15) limit on second prescription or refill. Patients must see their primary care doctor after the second refill.

NATIONWIDE COVERAGE SERVICES
Dr. John’s Medical Solutions telehealth services are available nation-wide. Services comply with appropriate state
regulations. The service does not discriminate based age. Consultation to children less than 18 years of age must
include a parent or guardian.
P. O. BOX 945, BRENTWOOD, TN 37024-0945 * (615) 791-6247 * info@docjmd.com * www.docjmd.com
COMPLAINTS, NOTIFICATIONS, AND OTHER INQUIRIES
For complaints, notifications, and other inquiries please contact:
Burke Mays, CEO
Dr. John’s Medical Solutions, Inc.
P. O. Box 945
Brentwood, TN 37024-0945
burke.mays@docjmd.com
800-257-9214, Ext 5
By purchasing and receiving telehealth services as provided by Dr. John’s Medical Solutions and Salus Telehealth I
agree to these Terms and Conditions.

Privacy Policy

 

Notice of Privacy Practices
This notice describes how medical information about you may be used and disclosed and how you can get access to this information.
Your Rights
You have the right to:
  • Get a copy of your paper or electronic medical record
  • Correct your paper or electronic medical record
  • Request confidential communication
  • Ask us to limit the information we share
  • Get a list of those with whom we’ve shared your information
  • Get a copy of this privacy notice
  • Choose someone to act for you
  • File a complaint if you believe your privacy rights have been violated
Your Choices
You have some choices in the way that we use and share
information as we:
  • Tell family and friends about your condition
  • Provide disaster relief
  • Include you in a hospital directory
  • Provide mental health care
  • Market our services and sell your information
  • Raise funds
Our Uses and Disclosures
We may use and share your information as we:
  • Treat you
  • Run our organization
  • Bill for your services
  • Help with public health and safety issues
  • Do research
  • Comply with the law
  • Respond to organ and tissue donation requests
  • Work with a medical examiner or funeral director
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
Get an electronic or paper copy of your medical record
  • You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
  • We will provide a copy or a summary of your health
Ask us to amend your medical record
  • You can ask us to amend health information about you that you think is incorrect or incomplete. Ask us how to do this.
  • We may say “no” to your request, but we’ll tell you why in writing within 60 days.
Request confidential communications
  • You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
  • We will say “yes” to all reasonable requests.
Ask us to limit what we use or share
  • You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
  • If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.
Get a list of those with whom we’ve shared information
  • You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
  • We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

 

Get a copy of this privacy notice - You can ask for a paper copy of this notice at any time.

 

Choose someone to act for you
  • If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will ensure the person has this authority before we take any action.
Your Choices
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
In these cases, you have both the right and choice to tell us to:
  • Share information with your family, close friends, or others involved in your care
  • Share information in a disaster relief situation
If you are not able to tell us your preference we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
In these cases we never share your information unless you give us written permission:
  • Marketing purposes
  • Most sharing of psychotherapy notes
  • Sale of your information
In the case of fundraising we may contact you for fundraising efforts, but you can tell us not to contact you again.
Our Uses and Disclosures
We can use your health information and share it with other professionals who are treating you.We can use and share your health information to run our practice, improve your care, and contact you when necessary. We can use and share your health information to bill and get payment from health plans or other entities.
Electronic Exchange. Your information may be shared w/ other providers, labs and radiology groups through our EHR system as listed:

 

None

 

How else can we use or share your health information?
We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Help with public health and safety issues
We can share health information about you for certain situations such as:
  • Preventing disease
  • Preventing or reducing a serious threat to anyone’s health or safety
  • Helping with product recalls
  • Reporting suspected abuse, neglect, or domestic violence
  • Reporting adverse reactions to medications

Do research, Comply with the law, Respond to organ and tissue donation requests, Work with a medical examiner or funeral director.
We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

We can use or share health information about you:
  • For workers’ compensation claims • For law enforcement purposes or with a law enforcement official
  • With health oversight agencies for activities authorized by law
  • For special government functions as military, national security, and presidential protective services Respond to lawsuits and legal actions
Our Responsibilities
  • We are required by law to maintain the privacy and security of your protected health information.
  • We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
  • We must follow the duties and privacy practices described in this notice and give you a copy of it.
  • We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be
available upon request, in our office, and on our web site.
You Have A Right To File A Complaint If You Feel Your Privacy Has Been Violated
  • If you feel your Privacy Rights have been violated, please ask our staff for a Privacy Complaint Form. Our Security Officer will review the form and promptly notifiy you of the actions our office will take.
  • or You can file a complaint with the U.S. 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 http://www.hhs.gov/hipaa/filing-a-complaint/complaint-process/index.html
  • We will not retaliate against you for filing a complaint.

Dr. John’s Medical Solutions, Inc.
HIPAA Compliance Officer: Burke Mays
Phone: (615) 791-6247
This Notice of Privacy Practices is effective January 1, 2017

HIPAA AUTHORIZATION TO DISCLOSE MEDICAL RECORDS

Dr. John’s Medical Solutions

RECORDS WILL BE DISCLOSED TO:

Dr. John’s Medical Solutions, Inc.

Phone:

615-791-6247

Address

315 Springhouse Circle

Fax

(615) 794 -9792

City/State/Zip

City

Franklin

State

Tennessee

Zip

37067

For the Following Purposes:

X Continuity of Care and Billing Purposes

By Checking the Boxes Below, I Specifically Authorize the Use and/or Disclosure of the Following Health Information And/or Medical Records, If Such Information And/or Records Exist:

The Following Items Must Be Initialed to Be Included in the Use And/or Disclosure:

HIV/AIDS related information and/or records HBV, TB or Other Communicable Diseases.

Mental Health Informationand/or Records

Domestic Violence Information.

Genetic Testing Information and/or records

Drug/Alcohol diagnosis, treatment or referral information.

(Federal regulations require a description of how much and what kind of information is to be disclosed.)

Other

I understand that the person I am authorizing to use and/or disclose the information may not receive compensation for doing so.

I further understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment or payment of my eligibility for benefits. I may inspect or copy any information to be used and/or disclosed under this authorization.

Finally, I understand that I may revoke this authorization, in writing, at any time, provided that I do so in writing, except to the extent that action has been taken in reliance upon this authorization. Unless Revoked Earlier, this Authorization Will Expire in One Year from the Date of Signing or until.

I give authorization to the provider listed below to disclose a copy of the specific health/medical information identified above:

Sign by Printing Patient’s Name:

Date:

Sign by Printing Name of Legal Representative (if applicable):

Relationship to patient: