Healthcare Safety Subscription Documents

Healthcare Safety Subscription Documents

This Healthcare Safety Subscription Documents package establishes the terms under which the Subscriber enrolls in the Provider's safety services and authorizes the use and disclosure of protected health information as needed to deliver those services. Subscriber acknowledges that by signing below they accept the terms, fees, consents, and authorizations contained herein.

Enrollment Summary

Subscriber Name:    Provider Name:

Effective Date:    Subscription ID:

Subscriber Information

Emergency & Authorized Contacts

Insurance Information

Medical History & Current Health Information

Scope of Subscription Services

The Provider will deliver safety-related services as selected below. Services may be performed by Provider staff or designated agents and may require disclosure of health information necessary to perform the services.

Incident alerting and triage
Medication reminders and adherence support
Remote monitoring of vital signs or alerts
Telehealth access for urgent safety evaluation
Notifications to authorized contacts in an emergency

Risks, Benefits, and Alternatives

Benefits: Enrollment may enable earlier identification of safety risks, facilitate timely response, and coordinate care among providers and designated contacts.

Risks: There are no guarantees of prevention of all adverse events. Electronic communications and monitoring may have technical failures. Transmission of health information involves inherent privacy risks despite reasonable safeguards.

Alternatives: Participation is voluntary. Alternatives include standard care without enrollment in the Provider's safety subscription services.

Authorizations and HIPAA Release

By checking the boxes below and signing this form, Subscriber authorizes the use and disclosure of protected health information to Provider, Provider's agents, subcontractors, technology vendors, emergency contacts, pharmacies, and insurers, as reasonably necessary to provide the safety subscription services and to respond to safety incidents.

I authorize disclosure of my health information for care coordination and safety monitoring.
I authorize notification of my authorized contacts in accordance with the contact information provided.
I authorize release of medication information to my pharmacy for safety reconciliation.
I authorize sharing of information with my insurer for coverage coordination and claims related to safety services.

Revocation: Subscriber may revoke this authorization in writing at any time. Revocation will not affect actions already taken in reliance on this authorization prior to receipt of revocation by Provider.

Fees, Billing, and Renewal

Subscriber agrees to the subscription fee described below. Subscriber authorizes Provider to charge the designated payment method for recurring fees where selected.

I authorize automatic renewal and recurring billing of the subscription fee until I cancel in writing.

Cancellation, Withdrawal, and Termination

Subscriber may cancel subscription at any time by providing written notice to Provider at the Provider address listed above. Cancellations become effective on the date Provider receives written notice; fees already incurred prior to cancellation are non‑refundable unless otherwise specified in a separate agreement.

Representations, Warranties, and Indemnity

Subscriber represents and warrants that the information provided on this form is true and complete to the best of Subscriber's knowledge. Subscriber agrees to indemnify and hold Provider harmless from claims arising from Subscriber's failure to provide accurate information or to timely notify Provider of material changes to health status or contact information.

Limitations of Liability

To the extent permitted by law, Provider's liability for direct damages arising from the performance of subscription services is limited to subscription fees paid by Subscriber during the six months preceding the claim. Provider is not liable for indirect, incidental, special, or consequential damages.

Acknowledgement of Privacy Practices and Notices

I acknowledge that I have been offered or provided with Provider's Notice of Privacy Practices describing how my health information may be used and disclosed in connection with these services.

I acknowledge receipt of the Notice of Privacy Practices.

Attestations

By signing below, Subscriber attests that (1) Subscriber has provided complete and accurate health and contact information; (2) Subscriber has read and understands the terms of this subscription and the consents herein; and (3) Subscriber authorizes Provider and its agents to act consistent with this subscription for the period specified.

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