Consent to Treat and Receive Virtual Care

Effective Date: May 20, 2025

This Consent to Treat and Receive Virtual Care outlines your rights and responsibilities as a patient receiving telemedicine services from Cercanos. Please read it carefully.

1. Scope of Services

You are requesting telemedicine services from Cercanos, which may include primary care, chronic condition management, behavioral health support, nutrition counseling, and wellness and care coaching (“Services”). Telemedicine involves the delivery of healthcare services using interactive audio and/or video technology that enables you to consult with healthcare professionals remotely.

You will be seen by a Cercanos clinician who is licensed to practice in your state or territory, and who will provide a medical evaluation, diagnosis, treatment, and follow-up care via our secure, HIPAA-compliant telehealth platform.

2. Benefits and Risks of Telemedicine

Benefits:

  • Convenient and timely access to medical care from any private location

  • Reduced travel and wait times

  • Enhanced ability to manage chronic conditions remotely

Risks:

  • Potential for technical failures or disruptions (e.g., poor connectivity, dropped sessions)

  • Rare instances of unauthorized access despite safeguards

  • Limited ability to conduct physical examinations, which may impact diagnosis or treatment

  • Incomplete or inaccurate information due to remote communication may increase risk of clinical error

3. Consent to Treatment

By agreeing to this consent, you authorize Cercanos and its affiliated clinicians and care team to:

  • Provide telehealth consultations and treatment via audio, video, or digital communications

  • Access and use your medical history and relevant health information for diagnosis and treatment

  • Document and store information about your consultation in accordance with privacy laws

You understand that you may not receive prescriptions for controlled substances or drugs with abuse potential through Cercanos telemedicine services.

4. Limitations and Appropriateness

Telehealth may not be appropriate for all medical conditions. You understand that:

  • Telemedicine is not a substitute for in-person care in emergency or life-threatening situations

  • Cercanos clinicians may refer you to in-person care, a local provider, or emergency services if medically necessary

If you experience a medical emergency, you should call 911 or go to the nearest emergency room immediately.

5. Privacy and Confidentiality

Your information is protected under applicable laws including HIPAA. Cercanos uses encryption and secure platforms to protect your PHI.

You agree:

  • Not to record your session or share your login credentials

  • To be in a private, secure location during your visit

  • That clinicians will not record sessions without prior written consent

6. Financial Responsibility

You are responsible for any visit fees or service charges not covered by your insurer, unless alternative payment arrangements have been made. You may be required to pay for services prior to or at the time of your visit, depending on your benefit plan.

7. Your Responsibilities

You agree to:

  • Provide complete and accurate health information during each visit

  • Update your medical records as needed, and at least annually

  • Participate in your treatment plan and follow clinical guidance

9. Right to Withdraw Consent

Your use of Cercanos services is voluntary. You may withdraw your consent at any time by ending your session. Doing so will not affect your right to receive future care.

10. Florida Weight Loss Treatment Consent (For Florida Residents Only)

This section applies only to Florida residents receiving care from Cercanos for weight loss treatment.

  1. By providing consent, I acknowledge that weight loss treatments carry potential risks and benefits, which I will discuss with my provider.

  2. Florida Weight Loss Bill of Rights:

Warning: Rapid weight loss may cause serious health problems. Rapid weight loss is weight loss of more than 1½ pounds to 2 pounds per week or weight loss of more than 1 percent of body weight per week after the second week of participation in a weight-loss program. Consult your personal physician before starting any weight-loss program. Only permanent lifestyle changes, such as making healthful food choices and increasing physical activity, promote long-term weight loss. Qualifications of this provider are available upon request.

You have the right to:

  • Ask questions about the potential health risks of this program and its nutritional content, psychological support, and educational components.

  • Receive an itemized statement of the actual or estimated price of the weight-loss program, including extra products, services, supplements, examinations, and laboratory tests.

  • Know the actual or estimated duration of the program.

  • Know the name, address, and qualifications of the dietitian or nutritionist who has reviewed and approved the weight-loss program according to s. 468.505(1)(j), Florida Statutes.

Data Protection and Security

We implement appropriate administrative, technical, and physical safeguards to protect your PHI. This includes:

  • Secure access controls

  • Encrypted communication and data storage

  • Regular audits and workforce training

You agree not to record any virtual session or disclose login credentials to others.

11. Communications and Digital Services

We may contact you by email, text message (SMS, Whatsapp), phone, or secure portal for appointment reminders, care coordination, or billing. You may opt out of certain communications as permitted by law.

We may collect limited technical information (such as IP address and device type) when you use our services for security and analytics purposes.

Patient Mobile Phone Contact Policy

Cercanos recognizes the importance of effective communication in providing high-quality, patient-centered care. By signing this agreement, patients authorize Cercanos to contact them via mobile phone for purposes related to their care, including but not limited to appointment reminders, care coordination, test results, prescription management, and other healthcare-related communications.

These communications may include calls, voicemails, text messages (SMS, MMS or Whatsapp) or other secure messaging platforms; Your use of the Service may be subject to separate third-party terms of service and fees, including, without limitation, the terms of service and data, SMS, MMS, and other fees of your mobile network operator which are your sole responsibility.Patients may opt out of receiving communications via mobile phone at any time by notifying Cercanos in writing. Cercanos will not share or sell mobile phone numbers to third parties and will ensure that all communication is conducted securely and respectfully.

SMS Consent Communication
The phone numbers obtained as part of the SMS consent process will not be shared with third parties for marketing purposes.

Types of SMS Communications
If you have consented to receive text messages from Cercanos, you may receive messages related to:

  • Appointment reminders

  • Follow-up messages

  • Billing inquiries

Example:
"Hello, this is a friendly reminder of your upcoming appointment with Dr. [Name] at [Location] on [Date] at [Time]. You can reply STOP to opt out of SMS messaging from Cercanos at any time."

Message Frequency
Message frequency may vary depending on the type of communication. For example, you may receive up to 5 SMS messages per week regarding your appointments, billing, or other services.


Potential Fees for SMS Messaging
Please note that standard message and data rates may apply depending on your carrier’s pricing plan. These fees may vary if the message is sent domestically or internationally.

Opt-In Method
You may opt-in to receive SMS messages from Cercanos in the following ways:

  • Verbally, during a conversation

  • By submitting an online form

  • By filling out a paper form

Opt-Out Method
You can opt out of receiving SMS messages at any time by replying "STOP" to any SMS message you receive. Alternatively, you can contact us directly to request removal from our messaging list.


12. Notice of Health Information Exchange and Data Sharing Policy

At Cercanos, your health and privacy are our top priorities. To provide you with the best possible care, we participate in Health Information Exchanges (HIEs), such as Carequality and CommonWell, which allow us to securely share and receive medical information from other healthcare providers involved in your care.

Why We Share Information

We share your health information to:

  • Coordinate your care with other doctors and hospitals.

  • Access up-to-date medical history, lab results, and medication lists.

  • Reduce unnecessary tests and procedures.

  • Improve your overall health outcomes.

How We Share Information

With your consent (or as permitted by law), Cercanos:

  • May share your medical records with other healthcare providers, payers, and authorized parties for treatment, payment, and healthcare operations.

  • May retrieve your medical information from Health Information Exchanges like Carequality and CommonWell to ensure continuity of care and accurate record-keeping.

Your Rights

  • You have the right to ask questions and request restrictions on how your information is shared.

  • You have the right to opt out of participation in Health Information Exchanges at any time by notifying our office in writing.

  • All data sharing complies with federal and state privacy laws, including HIPAA.

Your Consent

By signing below, you acknowledge that:

  • You have received this Notice of Health Information Exchange and Data Sharing Policy.

  • You understand that Cercanos may share and retrieve your health information through approved HIEs for the purposes of coordinating your care.

  • You have the right to ask questions or opt out at any time.

13. Medication History Access Policy

Cercanos is committed to providing safe, effective, and coordinated care for all patients. To support medication management and reduce the risk of medication errors, patients authorize Cercanos to obtain and access their complete medication history from pharmacies, electronic health records, and other healthcare providers as permitted by law.

This information will be used solely for clinical purposes, including medication reconciliation, treatment planning, and patient education. Cercanos will handle all medication history data in compliance with applicable privacy and security regulations, including HIPAA, and will not share this information with unauthorized parties. Patients may revoke this consent at any time by providing written notice to Cercanos.

14. Cercanos Financial Responsibility Agreement

We are committed to delivering accessible, culturally aligned, high-quality care. This document outlines our financial policies and your responsibilities as a patient. Please read it carefully and ask any questions before signing.

Patient Financial Responsibility

You are ultimately responsible for the payment of all services provided by Cercanos, regardless of your insurance coverage. This includes deductibles, co-payments, co-insurance, or any portion of the bill not paid by your insurance plan.

Insurance Verification and Billing

Cercanos will make reasonable efforts to verify your insurance coverage and submit claims on your behalf. However, it is your responsibility to:

  • Provide accurate and up-to-date insurance information prior to each visit.

  • Understand your insurance plan’s benefits, exclusions, and referral requirements.

  • Respond to any insurance requests needed to process claims.

If your insurance denies coverage or if authorization is not obtained in advance (when required), you will be responsible for the full amount due.

Payment Terms

  • Co-payments and any known patient responsibilities are due at the time of service.

  • If you are uninsured or your insurance coverage cannot be verified, you will be treated as a self-pay patient and are expected to pay in full at the time of your visit.

  • After your insurer processes the claim, you will receive a bill for any remaining balance.

Communication and Authorizations

By receiving services from Cercanos, you authorize us to:

  • Release necessary medical information to your insurance company, third-party payors, or healthcare providers involved in your care.

  • Contact you regarding your account using the contact information you provide, including text, email, or automated calls.

  • Apply insurance payments and any overpayments to your account or future balances.

Non-Covered and Out-of-Network Services

If services are considered non-covered or out-of-network by your plan, you are responsible for all resulting charges. You will be informed of known out-of-network or non-covered service risks in advance, when possible.

Returned Payments

Returned checks or declined payments are subject to a service fee of $25. We reserve the right to electronically debit your account for the amount due plus any applicable processing fees.

Collections and Legal Action

If our account is overdue for more than 90 days, it may be referred to a collection agency. You are responsible for any costs associated with collection efforts, including legal and court fees, as permitted by law.

Ancillary Services

You may receive separate bills for services such as labs, imaging, or specialists not employed by Cercanos. These are the responsibility of the patient and may be billed independently.

Billing Questions

If you have any questions regarding your billing, payments, or account balances, please contact our billing team at billing@cercanoscare.com. We are committed to providing you with clear, timely, and helpful information regarding any financial aspects of your care at Cercanos.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with us at:

Cercanos Privacy Office
Email: privacy@cercanoscare.com
Mailing Address: 66 W Flagler St, Suite 900. Miami, FL, 33130
Phone: 786-708-7344

 Acknowledgment

By continuing with this virtual visit, you acknowledge that:

  • You have read and understand this Consent to Treat and Receive Virtual Care

  • You agree to receive services from Cercanos via telemedicine

  • You understand the limitations, risks, and benefits of virtual care

Contact Us

If you have questions about this Notice or would like more information, please contact us at privacy@cercanoscare.com

Thank you for trusting Cercanos with your care.