Clinical Services and Practice Policies Agreement

Last revised: 07/21/2022

General Information

Summer Health Medical Group, P.A., and its associated medical groups (collectively “Summer Medical”, “we”, “our” or “us”) provides pediatric telehealth services for children through its engaged clinicians and sub-clinical specialists (the “Care Team”) with non-clinical support from its technology partner, Summer Health, Inc. (“Summer Health”).  This Agreement describes Summer Medical services and clinical programs.  It is important for you to read this document and discuss any questions you might have with us.

Our Services and Technology

When your Family Member becomes a patient of Summer Medical (a “Member”), you will be given access to the online platform of Summer Health (the “Summer Health Platform”) and our Care Team. The Summer Health Platform provides personalized content and interactive resources for you, simple tools for scheduling appointments and billing, serves as your hub of information including medical records, and connects you to our Care Team.  Your Care Team will be with you every step of the way and work collectively to support high quality, effective care. For purposes of this Clinical Services and Practice Policies Agreement, “you” means you on behalf of yourself and your Family Member.

Payment and Billing

Each bill for all charges must be paid by the date shown on the bill. By providing us with your credit card information, you are authorizing us to charge your credit card for agreed upon purchases and save your credit card information for future transactions on your account.  

Telehealth Informed Consent - Risks and Benefits

Your Care team will provide medical care via telehealth using asynchronous messaging servicesand SMS text. They may prescribe you medication or recommend other treatment, as needed. Telehealth care is a flexible and convenient way to get healthcare, but it may not be right for treating certain symptoms or illnesses that need an in-person doctor or urgent care visit.  We do not provide emergency care or handle medical emergencies. If you are having a medical emergency, call 9-1-1 or go to the nearest emergency room.

You have a right to know who is attending each telehealth visit. You may decide that you do not want to use telehealth services at any time. This will not make you lose your health program benefits or your rights to future health care. Telehealth services are convenient and offer better access to health care. However, as with any health service, there are potential risks associated with using technology. These risks include service problems due to technology or internet failures, not having enough information to make health care decisions, rare security errors, and other risks. You agree to take on the risk for information lost due to technology problems.

Privacy Practices

We use standard physical, electronic, and business security methods to help prevent access to your health information by people who should not see it. But we cannot promise that data sent over the Internet, SMS text, or through a data storage facility will be secure. So, although we try to protect your personal information, we cannot guarantee the security of any information you send to us.

We may share your health records with the following individuals under the following circumstances:

● With your other health care providers (including your primary care provider), either directly or through our participation in health information exchanges, and for healthcare coordination, operations and treatment purposes. This may include information relating to genetic tests, substance abuse, mental health, communicable diseases and other health conditions.

● With other individuals involved in your care such as caregivers or family members.  

● As otherwise permitted in our Health Information Privacy Practices and by applicable law.  

By signing below, you agree to let us share your records as described above and acknowledge receipt of the Health Information Privacy Practices.

SMS and Email Communications

As part of providing services, our Care Team will primarily communicate with you, including for clinical, clinical triage and treatment purposes, via SMS text messages and emails. Text messages and emails are not always secure because they travel over unencrypted networks that we do not control.

By signing below and providing us your cell phone number and email address, you permit us to communicate with you by SMS text message and email. You may also ask us to stop by contacting your Care Team. You understand that you may have to pay data costs to receive SMS text messages that we send to your mobile phone.  

Children’s Online Privacy Protection Act

As part of the services, we will collect the personal information of your child. Your consent is required for the collection, use, and disclosure of your child’s information. We will not collect your child’s personal information unless you consent. However, if you do not give your consent, your child may not use our services.

The types of personal information we collect directly from a child is:

● any information the child provides to us during an appointment, including health related information, or while logged into the account you created if you provide the child with your credentials (we do not allow children under age 18 to register directly for an account at this time);

● information about the child’s use of the services, including information sent by the mobile device or computer used by the child (e.g., IP address, unique device identifiers, website usage information, etc.) and information sent by the mobile device(s); and location information.

We use and disclose that information:

● to provide the services;

● for business analytics purposes;

● for our own marketing purposes;

● to provide customer support to you;

● for account and network security purposes;

● to maintain legal and regulatory compliance; and

● to enforce compliance with our agreements and policies.

Your agreement below constitutes your consent to the collection, use, and disclosure of your child’s information, as described in this Clinical Services and Practice Policies Agreement, our Privacy Policy, and our Health Information Privacy Practices. A parent or guardian may revoke this consent at any time. However, once consent is revoked, a child may not use our online services again unless a new Clinical Services and Practice Policies Agreement is signed.

Parent Attestation

In order to authorize health services for your child, you must have either sole or joint legal custody of your child. If you are separated or divorced (or become separated or divorced) from the other parent of your child, you agree to immediately notify the other parent that Summer Medical is providing health services to your child. You also agree to provide, if we make a request, a copy of the most recent custody decree that establishes custody rights of you and the other parent or otherwise demonstrates that you have the right to authorize treatment for your child.  If there are any changes in the status of legal guardianship/parent status, you understand that it is your responsibility to promptly notify Summer Medical of any such changes.  

One risk of pediatric care involves disagreement among parents and/or disagreement between parents and the child’s clinician regarding the child’s treatment. You agree to notify us immediately if such a disagreement occurs.  If such disagreements occur, we will strive to listen carefully so that we can understand your perspectives and fully explain our perspective.   If either parent decides that our health services should end, Summer Health will honor that decision, unless there are extraordinary circumstances.

During the treatment of your child, Summer Medical may meet with the child’s parents/guardians either separately or together. Please be aware that Summer Medical’s patient is the child – not the parents/guardians nor any siblings or other family members of the child. Furthermore, any communication by a parent may be legally disclosed to the other parent. A parent should NOT share any information which they are not willing to have disclosed to the other parent.  

You hereby certify that you have legal authority to authorize Summer Medical to provide medicalservices to your child. You further certify that you are not a party to or otherwise the subject of any agreement or court order that requires the written approval of the child’s other parent or any third party to authorize medical services for your child.  

Complaint Policy

All Members have the right to communicate grievances regarding their care. Should you wish to make a formal complaint about one of your care providers you may do so in writing and submit the concern to Summer Medical at

Agreement and Consent

If you have questions about any of the contents of this clinical services agreement, our procedures, or your role in this process, please discuss them with your Care Team. Remember that the best way to assure quality treatment is to keep communication open and direct with your clinician(s).

By signing below, you indicate that you have read and understood this document, and that you agree to abide by its terms. Further, you certify that if you are signing as a personal representative of the Member, you have legal authority to provide consent for the treatment of the Member.