There are four steps to this process.

1. 1. Entering your personal information into our secure web portal


2. 2. Understanding remote monitoring, it’s limitations and giving your informed consent for Remote Patient Monitoring Services.


3. 3. Understanding the privacy practices of Kirk G Voelker MD, PA including your rights to your health data and security measures implemented to protect that data as well as how we may use and/or disclose your health information.


4. 4. Understanding the Insurance billing process.

After completing this information, you will receive a text with your log on credentials for the MiHealth App as well as an introductory e-mail. Our staff will then contact you to answer additional questions,review your goals and discuss initial equipment requirements.

This is your first step to a safer, healthier life. Thank you for allowing us to be part of it.

Informed Consent

Kirk G. Voelker, M.D., P.A.
Informed Consent for Remote Patient Monitoring Services

Remote Patient Monitoring (RPM) involves the use of electronic communications and devices that automatically record data to enable healthcare providers at different locations to monitor physiologic metrics and share individual patient medical information for the purpose of managing patient care. In providing RPM services Kirk G. Voelker, M.D., P.A. (“Group”) and Group’s physicians (“Physician”) will the monitor a variety of physiologic metrics and track general health trends over days, weeks or months. Our program includes a variety of applications and services using remote patient monitoring devices including, without limitation, blood pressure, blood glucose, oxygen levels, weight, heart rate and/or activity (steps). Our staff may communicate with you using the text/phone/video functions of the MiHealth app.

OUR PROGRAM IS NOT DESIGNED TO MANAGE YOUR MEDICAL CARE AND WE DEFER MEDICAL DECISIONS TO YOUR DOCTORS.

MiHEALTH IS NOT AN EMERGENCY RESPONSE UNIT AND IS NOT MONITORED 24/7. CALL 911 for EMERGENT SERVICES

The information from your devices is available to MiHealth only after it is uploaded from the device to our system and therefore is not considered “real time” monitoring. 

The MiHealth Remote Patient Monitoring Team will view this information Monday to Friday between 8 a.m. and 5PM, not including statutory holidays

The electronic monitoring systems we use will incorporate network and software security protocols to protect the confidentiality of patient identification and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

These RPM services are an addition to, and not a replacement for, your primary care physician. Responsibility for your overall medical care should remain with your primary care doctor, if you have one, and we strongly encourage you to locate one if you do not.

OUR PHYSICIANS DO NOT ADDRESS MEDICAL EMERGENCIES. IF YOU BELIEVE YOU ARE EXPERIENCING A MEDICAL EMERGENCY, YOU SHOULD DIAL 9-1-1 AND/OR GO TO THE NEAREST EMERGENCY ROOM. PLEASE DO NOT ATTEMPT TO CONTACT GROUP, OR A GROUP PHYSICIAN FOR EMERGENCY CARE. 

Expected Benefits:

• Improved access to care by enabling you to remain in your home while a clinical care team obtains results at distant/other sites.
• More efficient care evaluation and management.

Possible Risks:

• Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment and technologies.
• In rare events, a Group Physician may determine that the transmitted information is of inadequate quality, thus necessitating an in-person meeting with your primary care doctor
• In very rare events, security protocols could fail, causing a breach of privacy of personal medical information

By checking the box associated with "INFORMED CONSENT", you acknowledge that you understand and agree with the following:

1. I hereby consent to receiving RPM services. I understand that the RPM services are provided in connection with my current treatment plan with the Physician
2. I understand that federal and state law requires health care providers to protect the privacy and the security of health information. I understand that the Physician will take steps to make sure that my health information is not seen by anyone who should not see it, in accordance with Physician’s standard practices. I understand that RPM services may involve electronic communication or monitoring of my personal medical information to or by other health practitioners or clinical staff who may be located in other areas, including out of state
3. I understand there is a risk of technical failures during the RPM services beyond the control of the Group Physician. I agree to hold harmless Group and Physician for delays in evaluation or for information lost due to such technical failures.
4. I understand that I have the right to withhold or withdraw my consent to RPM in the course of my care at any time, without affecting my right to future care or treatment. I understand that I may suspend or terminate use of the RPM services at any time for any reason or for no reason. I understand that if I am experiencing a medical emergency, that I will be directed to dial 9-1-1 immediately and that Physician or Physician’s clinical staff are not able to connect me directly to any local emergency services.
5. I understand that I may expect the anticipated benefits from the use of RPM in my care, but that no results can be guaranteed or assured. 
6. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Persons may be present during consultations or communications with Group and my Physician in order to operate the RPM technologies. I further understand that I will be informed of their presence during such consultation/communications and thus will have the right to request the following: (1) omit specific details of my medical history/examination that are personally sensitive to me; (2) ask non-medical personnel to leave; and/or (3) terminate the consultation/communication at any time.
7. I understand I can request to obtain a copy of my medical record and request that copies be sent to my primary care provider or other designated health care provider of record. I can request to obtain or send a copy of my medical records by calling (877) 200-2777. A copy will be provided to me at reasonable cost of preparation, shipping and delivery

Patient Consent 

I have read this document carefully, and understand the risks and benefits of the RPM services and have had my questions regarding the services explained and I hereby give my informed consent to participate in the RPM services program.

 By checking this Box, I acknowledge that I have carefully read, understand, and agree to the terms.

Privacy Policy

Kirk G. Voelker MD, PA

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. PLEASE REVIEW IT CAREFULLY.

We are required by law to maintain the privacy of your protected health information, to notify you of our legal duties and privacy practices with respect to your health information, and to notify affected individuals following a breach of unsecured health information. This Notice summarizes our duties and your rights concerning your information. Our duties and your rights are set forth more fully in 45 CFR

1. Uses And Disclosures We May Make Without Written Authorization. We may use or disclose your health information for certain purposes without your written authorization, including the following:

• Treatment. We may use or disclose your information for purposes of treating you. For example, we may disclose your information to another health care provider so they may treat you; to provide appointment reminders; or to provide information about treatment alternatives or services we offer.
• Payment. We may use or disclose your information to obtain payment for services provided to you. For example, we may disclose information to your health insurance company or other payer to obtain pre-authorization or payment for treatment.
• Healthcare Operations. We may use or disclose your information for certain activities that are necessary to operate our practice and ensure that our patients receive quality care. For example, we may use information to train or review the performance of our staff or make decisions affecting the practice.
• Other Uses or Disclosures. We may also use or disclose your information for certain other purposes allowed by 45 CFR § 164.512 or other applicable laws and regulations, including the following:    
• To avoid a serious threat to your health or safety or the health or safety of others. As required by state or federal law such as reporting abuse, neglect or certain other events. As allowed by workers compensation laws for use in workers compensation proceedings. For certain public health activities such as reporting certain diseases. For certain public health oversight activities such as audits, investigations, or licensure actions. In response to a court order, warrant or subpoena in judicial or administrative proceedings.
• For certain specialized government functions such as the military or correctional institutions. For research purposes if certain conditions are satisfied. In response to certain requests by law enforcement to locate a fugitive, victim or witness, or to report deaths or certain crimes. To coroners, funeral directors, or organ procurement organizations as necessary to allow them to carry out their duties.

2. Disclosures We May Make Unless You Object. Unless you instruct us otherwise, we may disclose your information as described below. To a member of your family, relative, friend, or other person who is involved in your healthcare or payment for your healthcare. We will limit the disclosure to the information relevant to that person’s involvement in your healthcare or payment.

3. Uses and Disclosures with Your Written Authorization. Other uses and disclosures not described in this Notice will be made only with your written authorization, including most uses or disclosures of psychotherapy notes; for most marketing purposes; or if we seek to sell your information. You may revoke your authorization by submitting a written notice to the Privacy Contact identified below. The revocation will not be effective to the extent we have already taken action in reliance on the authorization.

4. Your Rights Concerning Your Protected Health Information. You have the following rights concerning your health information. To exercise any of these rights, you must submit a written request to the Privacy Officer identified below.

You may request additional restrictions on the use or disclosure of information for treatment, payment, or healthcare operations. We are not required to agree to the requested restriction except in the limited situation in which you or someone on your behalf pays for an item or service, and you request that information concerning such item or service not be disclosed to a health insurer. We normally contact you by telephone or mail at your home address. You may request that we contact you by alternative means or at alternative locations. We will accommodate reasonable requests. You may inspect and obtain a copy of records that are used to make decisions about your care or payment for your care, including an electronic copy. We may charge you a reasonable cost-based fee for providing the records. We may deny your request under limited circumstances, e.g., if we determine that disclosure may result in harm to you or others. You may request that your protected health information be amended. We may deny your request for certain reasons, e.g., if we did not create the record of if we determine that the record is accurate and complete. You may receive an accounting of certain disclosures we have made of your protected health information. You may receive the first accounting within a 12-month period free of charge. We may charge a reasonable cost-based fee for all subsequent requests during that 12-month period. You may obtain a paper copy of this Notice upon request. You have this right even if you have agreed to receive the Notice electronically

5. Changes To This Notice. We reserve the right to change the terms of this Notice at any time, and to make the new Notice effective for all protected health information that we maintain. If we materially change our privacy practices, we will post a copy of the current Notice in our reception area and on our website. You may obtain a copy of the operative Notice from our receptionist or Privacy Officer.

6. Complaints. You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated. You may file a complaint with us by notifying our Privacy Officer. All complaints must be in writing. We will not retaliate against you for filing a complaint.

7. Contact Information. If you have any questions about this Notice, or if you want to object to
or complain about any use or disclosure or exercise any right as explained above, please
contact:

Compliance & Privacy Officer:
Kirk G. Voelker MD
Phone: (833) 200-2777
Address: 15 Paradise Plaza, Ste 184
Sarasota, FL 34239
E-mail: support@mihealthmonitoring.com

 I acknowledge that I have reviewed this office’s Notice of Privacy Practices and agree to the terms stated within.

 I understand I am responsible for authorizations required by my insurance company for follow-up testing and office visits. 

 I request that payment of authorized Medicare benefits be made on my behalf to Kirk G. Voelker MD for any services furnished by the entity. I authorize any holder of medical information to release to the Health Care Financing Administration and its agent any information necessary to determine these benefits or the benefits payable for related services.

Payment Consent

Kirk G. Voelker, M.D., P.A.

CONSENT TO PAYMENT FOR REMOTE PATIENT MONITORING SERVICES

I understand that the remote patient monitoring services are separate services for which Kirk G Voelker MD,PA will bill my insurance payers, including Medicare or

Medicaid. 

I understand that my payer, such as Medicare, may not cover all of the billed amount. I understand I am responsible for paying Medical Group for any and all of such amounts not paid by my insurance payer, including non-covered charges and all copayments and deductibles. 

 By checking the Box for this "REMOTE PHYSIOLOGIC MONITORING CONSENT TOCO- PAYMENT" I hereby state that I have read, understood, and agree to the terms of this document.

Insurance Information

PRIMARY INSURANCE

SECONDARY INSURANCE