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TABLE OF CONTENTS
1. Consent to Treatment
2. Notice of Privacy Practices
CONSENT TO TREATMENT
Please read this information carefully and ask questions if you do not understand. If you would like an interpreter, we will provide one at no charge. By using the Platform, you are agreeing and consenting to the information within.
You understand that Summit is a participant of the Arizona statewide Health Information Exchange (HIE). For more information on the HIE you may visit the Health Current website.
You understand that you may Opt Out of the HIE by emailing email@example.com and requesting an Opt Out form.
Patient Bill of Rights and Responsibilities
You acknowledge you have received a copy of the Patient Bill of Rights and Responsibilities.
NOTE: You may ask for a copy of the Patient Handbook, Bill of Rights and Responsibilities and/or the Notice of Privacy Practices at any time. These documents may also be viewed on the Summit Healthcare Association website.
Physicians and Medical Providers
- Summit works with a variety of physicians, medical providers and/or groups who may be employed, contracted or independent. They provide professional services to patients which are often billed separately. These services may include telemedicine.
- The independent physicians and contracted providers are neither employees nor agents of Summit and neither party is responsible for the acts of the other party.
Authorization for Treatment
- I consent to the rendering of medical care and treatment as my physician(s) or other medical staff consider to be necessary and beneficial to me. I authorize Summit, its employees, agents, students and physicians caring for me to treat my condition(s), provide customary telemedicine services and/or consultations.
- My care is under the control and direction of my attending physician, specialist, or requested consultant, and Summit is not responsible, nor liable for the control and direction of the physicians or their instructions.
- I have been informed of the treatment and/ or procedures considered necessary for my condition(s). No guarantees have been made to me regarding the results of my examination or treatment.
Authorization to Assign Insurance Benefits and Release Information to Summit
- I authorize my Payer(s) to directly pay Summit any benefits due under the terms of my health care plan(s) for services provided to me, including physician services. I agree to assign the benefits payable for physician services to the physician or to Summit for services provided. I understand that it is the healthcare providers obligation to verify the medical necessity and authorization for all services prior to the services being provided. In the event it is determined that I, the patient, provided incomplete or inaccurate information leading to a claim denial, I agree to accept full financial responsibility.
- If my Payer(s) will not allow direct payment to Summit or if Summit chooses not to accept assignment of medical benefits, I agree to pay Summit all health care payments I receive directly for services provided.
Authorization to Release Medical information
- I authorize Summit to contact my Payer(s) to obtain all pertinent financial information concerning coverage and payments made under my health care plan(s) and for my Payer(s) to release such information to Summit. Payers include Medicare and its agents, insurance carriers, health plan administrators, utilization review agencies, third party payers, or any other government or private payer responsible for payment of charges.
- I authorize Summit to release all necessary medical information to applicable Payers for the processing and billing of my health care claims. Medical information which may be released includes but is not limited to behavioral health notes, communicable diseases and alcohol and drug related treatment.
- I authorize Summit and my Payer(s) to share my past, current and future health, treatment and account records about the services I have received from Summit and other care providers as needed to manage or coordinate my care and to improve the quality of that care.
- I authorize Summit to release all necessary medical information to the person(s) I designate as my Billing Addressee/Guarantor for handling the billing, payment and health care coverage for my account.
Statement of Financial Responsibility
- I acknowledge I am responsible for all charges for the services provided to me, including any amount not paid by my health care plan(s) or any third party payer, other than billing terms and restrictions under a government program. I agree in return for the services provided by Summit or by the independent contractor. I am obligated to pay my account and/or make satisfactory financial arrangements prior to visit completion.
- I agree that Summit may obtain financial information, including consumer credit reports to determine eligibility for financial assistance and/or payment options.
- If my account is sent to an attorney or collection agency. I agree to pay reasonable attorneys’ fees and collection expenses. A delinquent account will be subject to interest at the legal rate.
Health Plan and Insurance Contracts
Summit contracts with various health plans and a list is available upon request. I acknowledge it is my responsibility to determine if my health plan is contracted with Summit, as well as the independent physicians and contracted providers who bill separately for the services provided to me. I am responsible for understanding the terms and conditions of my health benefit plan and the associated physician and provider networks.
Use of Phone To Contact
I agree Summit, its affiliates and agents may use common business technologies to contact me. This includes the use of an automated telephone dialing system, pre-recorded voice messages and texting to contact the wireless number(s) and/or residential lines I provide to Summit for medical care, appointment and payment purposes.
ATTENTION: This is a legal document. Requests for any alterations must be made by calling (928) 537-6556. I agree that I understand and accept this Consent to Treatment. If you are accessing and using the Platform on behalf of a legal dependent, please select the patient’s relationship to you: Child or Legal Guardian. I understand I have the right to revoke my authorization at any time by notifying Summit in writing, except to the extent that Summit has already taken action in reliance upon them. These authorizations will remain valid until I revoke them in writing.
NOTICE OF PRIVACY PRACTICES
You acknowledge receipt of Summit’s Notice of Privacy Practices.
Summit Healthcare Association (“Summit,” “our” or “we”), acting on behalf of its subsidiaries, affiliates, and licensors, provides this mobile app and Summit telehealth website (“SummitCares Platform” or the “Platform”) to you, the end user (“you” or “your” or “I”) in order to provide you access to certain telemedicine services and consultations (“Services”) provided by Summit physicians (each a “Provider”). Except where expressly noted otherwise, the Platform consists of all pages located here: www.summitcares.net
Please read this agreement carefully before accessing or using the Platform. By accessing or using the Platform, you agree to the Terms. If you do not agree to these Terms, do not use the Platform.
Summit may revise these terms from time to time. If we make any revisions, we will notify users by posting a notice regarding the revisions on this Platform. Revisions will be effective as of their posting unless otherwise stated. By accessing or using this Platform after such revisions are posted, you agree and consent to all such revisions. Do not use this Platform if you do not agree to the changes.
Platform Content and Access
Summit reserves the right without prior notice to discontinue any Platform features, functions or content available on this Platform at any time without incurring any obligations to you or any other party. Statistics provided on this Platform are based upon patient and physician reporting and survey responses. Individual results from use of the Platform or Services may vary.
The content on this Platform, including without limitation the text, graphics, logos, button icons, images, video and audio clips, digital downloads, data compilations and software, is owned or licensed by Summit, the Providers or their respective affiliates or vendors and is protected under applicable United States and international patent, copyright, trademark and other intellectual property laws. The compilation of all content on this Platform, as well as the original arrangement, organization, design, formatting, trade dress, look and feel of the Platform is also the exclusive property of Summit, the Providers or their respective affiliates or vendors and is also protected by United States and international intellectual property laws. This Platform may contain various third-party names and marks that are the property of their respective owners.
Any unauthorized use of our marks or of our copyrighted material or trade dress or any other intellectual property is strictly prohibited and may be prosecuted to the fullest extent that the law provides.
You may post or submit to the Platform reviews, comment, photos, and submit personal and/or health information ideas, suggestions or questions and other content (“Content”). Summit will not have any obligation of any kind to you with respect to any postings, feedback or data that you submit. You hereby grant to Summit a perpetual, worldwide, royalty-free, full paid-up irrevocable right and license in your Content and you agree to assign and hereby assign all such postings, feedback and data to Summit without charge, which we may sublicense, to: (a) use, copy, reproduce, perform, display, publish and distribute (internally and externally) copies of, the Content (including any trademarks that consist of text or that are embedded or incorporated into such Content, e.g., a logo in a product image); and (b) adapt, modify, re-format and create derivative works of such Content which derivative works are also subject to the license set forth herein. Our rights to the Content will apply to the Content in any form or medium, whether now known or hereafter known.
Any submissions through the Platform in connection with the Services will be maintained as confidential as required by law and Summit’s obligations to the Providers.
License to Access
You are granted a limited, revocable license to access and make use of the Platform to manage view, copy, print and use content contained on this Platform solely for your own personal or internal use, provided that: (1) it is used for informational and non-commercial purposes only; (2) no text, graphics or other content available from this Platform is modified or framed in any way; and (3) no graphics available from this Platform are used, copied or distributed separate from accompanying text. The use of any content for commercial purposes is expressly prohibited. Nothing in these Terms is intended to, or may be construed as, conferring by implication, estoppel or otherwise any license or other grant of right to use any patent, copyright, trademark, service mark or other intellectual property of Summit or any third party, except as expressly provided in this section.
Acceptable Use of the Platform
You may not use, copy, modify, duplicate, distribute, translate, reproduce, republish, disassemble, reverse engineer, decompile, mirror, frame, hyperlink or transmit any of the content or materials of this Platform or rent or sell use of or access to (such as on a time share or service bureau basis) this Platform, or any of the content or materials on this Platform. You may not permit third parties to access this Platform or use any Platform content and may not make any other use of the Platform or any Platform content except as set forth in this Agreement, unless otherwise expressly agreed to in writing by Summit. You may not harvest or collect information about others, including e-mail addresses. Any conduct by you that, in our discretion, restricts or inhibits any other person from using or enjoying the Platform will not be permitted.
You acknowledge and agree (1) that your use of this Platform is at your own discretion and risk, (2) that use of any material, information or data downloaded or otherwise obtained through the use of this Platform is at your own discretion and risk, and (3) that you are solely responsible for any damage to your computer system for loss of data that results from the download of such material, information or data, and for any other form of damage that may be incurred.
You will need an email address/user name and password to set up your Platform account. You are responsible for maintaining the confidentiality of your user name and/or password and for restricting access to your account. You agree to accept responsibility for all activities that occur under your account or password. You agree to provide only current, complete, accurate and truthful information. If you are accessing and using the Platform on someone else’s behalf, then you represent that you have the authority to bind that person as the principal to these Terms. To the extent you do not have such authority you agree to be bound to these Terms and to accept liability for harm caused by any wrongful use of the Terms resulting from your access or use. We reserve the right to refuse service and/or terminate accounts without prior notice if these Terms are violated or if we decide, in our sole discretion, that it would be in our best interests to do so.
Except as otherwise agreed in writing, you will not (a) circumvent or attempt to circumvent, interfere, breach or abuse the security measures implemented to limit access and protect the Platform, information provided through use of Summit, and the resources used to provide the Platform; (b) disrupt or interfere with the operation of the Platform or the resources used to provide the Platform; (c) transmit through the Platform any virus, trojan horse, or similarly harmful, disruptive or destructive computer program, script or object; (d) monitor, mirror, copy, summarize or create any derivative work from some or all the Platform or any materials used to provide the Platform (including the underlying software); (e) use another person’s account or password to access the Platform or otherwise obtain unauthorized access to the Platform or the data or information of another person; (f) use the Platform in any illegal manner or for any illegal purpose, or any other manner or purpose that would expose us or our service providers to civil or criminal liability; (g) use the Platform to transmit any form of unsolicited commercial e-mail or similar messages or otherwise use Summit for commercial purposes; (h) transmit or communicate to us or our Service Providers any information that is illegal or which you do not have permission to transmit or communicate; (i) reverse engineer, decompile or reverse assemble any software used to provide the Platform; (j) use the Platform in any manner that could reasonably be expected to damage, disable, overburden or impair access to or the functionality of the Platform; (k) interfere with the security of, or otherwise abuse the Platform or the system resources, accounts, servers or networks that support, are connected to or are accessible through the Platform; and (l) attempt, or permit or authorize any other person to do, or omit to restrict any user from doing, any of the foregoing. We reserve the right to suspend or restrict the provision of the Platform as we determine in our sole discretion.
Third Party Platforms and Third Party Pages
This Platform may produce automated search results or otherwise link you to other websites on the Internet, called “Third Party Pages,” or may contain links to, or be accessed through links on, websites managed and operated by or on behalf of third party entities (“Third Party Platforms”). These third parties are separate and independent entities and are not agents of Summit. Summit does not have control over such third party websites or the content of such websites. As a result, Summit does not endorse and does not have responsibility for the information, misinformation, errors, availability, operation or performance of any such third party website to which this Platform may link or from which this Platform may be accessed.
Reference to any product, recording, event, process, publication, service, or offering of any third party by name, trade name, trademark, service mark, company name or otherwise does not constitute or imply the endorsement or recommendation of such by Summit. Any views expressed by third parties on this Platform are solely the views of such third party and Summit assumes no responsibility for the accuracy or veracity of any statement made by such third party.
Summit is a “covered entity” subject to the federal Health Insurance Portability & Accountability Act of 1996 and its implementing regulations (“HIPAA”), as amended from time to time. Pursuant to HIPAA and other applicable laws and regulations, we have taken reasonable and appropriate measures to ensure the security of the Platform and the technology that supports and enables the app and the Website. However, no electronic system can be absolutely secure or error-free. The Notice of Privacy Practices explains how we use your health information.
This Platform and all information, services and related materials it contains are provided “as is,” “as available” and “with all faults.” Summit makes no representation or warranty whatsoever regarding the completeness, accuracy, currency, or adequacy of, or the suitability, functionality, availability, or operation of this Platform or the information or materials it contains. To the fullest extent permissible under applicable law, Summit, the Providers and their respective affiliates and vendors, specifically disclaim all warranties, express or implied, with respect to this website and the information and materials contained on this website, including without limitation the warranties of merchantability, fitness for a particular purpose, title and non-infringement and any warranties arising from a course of dealing or usage in trade.
Use of the Internet is inherently unreliable. As a result, neither Summit nor the Providers warrant that the platform or your access to the platform will be uninterrupted or error-free, that defects in the platform will be corrected, or that this website or the server that makes it available are free of viruses or other harmful components. Neither Summit nor the Providers warrant or make any representations regarding the use or the results of the use of the materials in this Platform in terms of their correctness, accuracy, reliability, or otherwise.
While Summit takes commercially reasonable efforts to protect the privacy and confidentiality of your information and transactions, Summit cannot ensure any internet transaction is completely secure. Summit and its vendors use industry standard technology to help protect against the loss, misuse and alteration of the information under Summit’s control; however, Summit does not guarantee that such loss, misuse or alteration will not occur. You understand that use of the Internet and this Platform is at your own risk. Neither Summit, the Providers, nor their respective vendors, affiliates or suppliers is responsible for any virus or damage to your computer, computer software, or any loss of data that may result from use of the website or access to any Services.
This Platform may be unavailable from time to time due to mechanical, telecommunication, software, and third- party vendor failures. Summit cannot predict or control when such downtime may occur and cannot control the duration of such downtime. As a result, Summit cannot and does not have any liability for such failures.
Reasonable efforts are taken to ensure the accuracy and integrity of information and related materials provided by Summit on this Platform, but Summit is not responsible for misprints, out-of-date information, technical or pricing inaccuracies, typographical or other errors. Information and related materials are subject to change without notice.
No advice or information from Summit or the Providers in any manner will create any warranty as to this Platform or any product, service or material available through this Platform. If for any reason you are not satisfied with this Platform or its content, your sole remedy is to cease using this Platform or such content, even if such remedy should fail of its essential purpose.
Applicable law may not allow the exclusion of implied warranties, so the above exclusion may not apply to you.
LIMITATION OF LIABILITY
TO THE MAXIMUM EXTENT PERMITTED BY APPLICABLE LAW, IN NO EVENT WILL SUMMIT, THE PROVIDERS, OR ANY OF THEIR RESPECTIVE VENDORS, AFFILIATES, OFFICERS, MEMBERS, REPRESENTATIVES, SUPPLIERS, DIRECTORS, EMPLOYEES, CONSULTANTS, OWNERS, OR AGENTS BE LIABLE FOR DAMAGES OF ANY KIND, INCLUDING WITHOUT LIMITATION ANY DAMAGES FOR LOSS OF USE; LOSS OF DATA, CONFIDENTIAL OR OTHER INFORMATION; LOSS OF PROFITS, BUSINESS, REVENUE, EXPECTED SAVINGS; BUSINESS INTERRUPTION; PERSONAL INJURY INCLUDING BODILY INJURY AND DAMAGE TO TANGIBLE PROPERTY; OR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, EXEMPLARY, PUNITIVE OR CONSEQUENTIAL DAMAGES ARISING FROM OR OTHERWISE RELATED TO THIS PLATFORM OR YOUR USE OF OR INABILITY TO USE THIS PLATFORM, WHETHER SUCH DAMAGES ARE BASED IN TORT, CONTRACT, NEGLIGENCE, STRICT LIABILITY OR OTHERWISE, EVEN IF SUMMIT HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGES OR SUCH DAMAGES WERE OTHERWISE FORESEEABLE. YOUR SOLE AND EXCLUSIVE REMEDY IN THE EVENT OF SUCH DAMAGE IS TO DISCONTINUE YOUR ACCESS TO AND USE OF THIS PLATFORM. NOTWITHSTANDING THE FOREGOING, IN ANY EVENT, THE AGGREGATE LIABILITY OF SUMMIT, THE PROVIDERS AND THEIR AFFILIATES AND VENDORS FOR ANY REASON SHALL NOT EXCEED $100.00 US, EVEN IF SUCH REMEDY SHOULD FAIL OF ITS ESSENTIAL PURPOSE.
YOU AGREE TO DEFEND, INDEMNIFY AND HOLD HARMLESS SUMMIT, THE PROVIDERS, AND THEIR RESPECTIVE VENDORS, AFFILIATES AND THEIR OFFICERS, DIRECTORS, REPRESENTATIVES, EMPLOYEES, CONSULTANTS, AND AGENTS FROM AND AGAINST ANY CLAIMS, ALLEGATIONS, DAMAGES, LOSSES, LIABILITIES OR EXPENSES (INCLUDING, BUT NOT LIMITED TO ATTORNEYS’ FEES) THAT SUCH PARTY MAY SUFFER OR INCUR AS A RESULT OF (I) YOUR USE, MISUSE, OR INABILITY TO USE THE WEBSITE, (II) YOUR INFRINGEMENT OF ANY INTELLECTUAL PROPERTY OR OTHER RIGHT OF SUMMIT, OR ANY OTHER PERSON OR ENTITY, (III) YOUR VIOLATION OF ANY APPLICABLE LAW, INCLUDING WITHOUT LIMITATION ANY PRIVACY OR DATA SECURITY LAW OR REGULATION, OR (IV) YOUR VIOLATION OF THIS AGREEMENT. NOTWITHSTANDING THE FOREGOING, SUMMIT RESERVES THE RIGHT TO PARTICIPATE IN THE DEFENSE OF ANY SUCH CLAIM, SUBJECT TO YOUR INDEMNIFICATION OBLIGATION.
Platform for Use Only in the United States
The Platform is designed for and intended for use only in the United States. By using the Platform, you explicitly consent that all applicable United States laws, including those that pertain to data privacy, apply to your use of the Platform. If you are in a jurisdiction that either restricts you from accessing the Platform or limits the effect of the provisions of these Terms, you may not use the Platform. We make no representation that content and materials provided through Summit are legal or appropriate for use from outside the United States. If you access the Platform from outside the United States, you do so at your own risk. You may not use the Platform in violation of United States export laws and regulations.
Disputes and Interpretation
This Agreement is governed by and interpreted under the laws of the State of Indiana and the federal laws of the United States, without regard to conflicts of laws principles. This Agreement and access to the Website or systems, without the posting of a bond, proof of damages or other similar requirement. Certain provisions, by their nature or as explicitly stated, will survive any termination or expiration of this Agreement. If any of these conditions shall be deemed invalid, void, or for any reason unenforceable, that condition will be severable and shall not affect the validity and enforceability of any remaining condition.
Digital Millennium Copyright Act
If you have any copyright concerns about materials posted on the Platform, you agree to let Summit know. Pursuant to Title 17, United States Code, Section 512(C)(2), notifications of claimed copyright infringement should be sent to Summit’s Designated Agent. An effective notification contains the following:
- A physical or electronic signature of a person authorized to act on behalf of the owner of an exclusive right that is allegedly infringed.
- Identification of the copyrighted work claimed to have been infringed, or, if multiple copyrighted works at a single online website are covered by a single notification, a representative list of such works at that website.
- Identification of the material that is claimed to be infringing or to be the subject of infringing activity and that is to be removed or access to which is to be disabled, and information reasonably sufficient to permit the service provider to locate the material.
- Information reasonably sufficient to permit the service provider to contact the complaining party, such as an address, telephone number, and, if available, an electronic mail address at which the complaining party may be contacted.
- A statement that the complaining party has a good faith belief that use of the material in the manner complained of is not authorized by the copyright owner, its agent, or the law.
- A statement that the information in the notification is accurate, and under penalty of perjury, that the complaining party is authorized to act on behalf of the owner of an exclusive right that is allegedly infringed.
All inquiries not relevant to the following procedure will not receive a response. For more information contact:
Attn: Legal Department
2200 Show Low Lake Rd
Show Low, AZ 85901
The Platform is owned and operated by Summit Healthcare Association. If you have any questions about these Terms please contact us at:
Attn: Legal Department
2200 Show Low Lake Rd
Show Low, AZ 85901