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to CardioNet for any co-payments, co-insurance, deductibles, payments made directly to me
by my health insurance carrier for CardioNet services, and, when allowed by law, services not-
covered or payable under my health insurance plan. I also understand that activating monitoring
services serves as my electronic signature, and that I am accepting financial responsibility
as explained above for all payment for services received from CardioNet. By signing this
document and/or accepting these terms electronically, I acknowledge that I have received a
copy of CardioNet’s Notice of Privacy Practices. This acknowledgment is required by the Health
Insurance Portability and Accountability Act (HIPAA) to ensure that I have been made aware of
my privacy rights.
SERVICE AGREEMENT
Financial Terms I understand that I am fully responsible and agree to pay for any co-payments,
co-insurance, deductibles, all payments made directly to me by my insurer for CardioNet services,
and when allowed by law, services not-covered (not payable) under my health insurance plan.
I acknowledge that I am financially responsible for the loaned System (sensor, monitor, and
accessories), which I am obligated to return to CardioNet upon completion of the service. If I do
not immediately return the System, I hereby authorize CardioNet to invoice me for, and agree to
pay CardioNet, the value of the Monitoring System and any associated collection costs should
collection or legal costs be incurred by CardioNet.
OPERATIONAL NOTICES
I hereby acknowledge that, given the variance in cellular phone coverage and signal strength, the
System may not always provide continuous transmission of my ECG rhythm to the Monitoring
Center. In the event that there is no cellular phone coverage or adequate signal strength to
transmit recorded events, I will move to an area to optimize transmission capability or connect
the monitor and base to a direct telephone line as requested. I hereby acknowledge that the
System is intended to aid in diagnosis only, and is not designed for prevention or treatment of
any event or condition. I agree to immediately discontinue use of the System upon any sign
of discomfort or other problems directly related to the System, and to promptly report such
discomfort or other problems to BioTelemetry. I give BioTelemetry and its subsidiaries my
consent and permission to communicate with other members of my household, if necessary,
with regard to my BioTel Heart service. I also authorize BioTelemetry and its subsidiaries to
provide my monitoring data to my physician and his /her staff and to Emergency Medical
Services by phone, e-mail, fax or through secure Internet access.
NOTICE OF CONFIDENTIALITY AND 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.
PROTECTING YOUR HEALTH INFORMATION
BioTelemetry, Inc., together with its family of companies including CardioNet, LLC, Heart-
Care Corporation of America, Inc., LifeWatch Services, Inc. and Telcare Medical Supply, LLC
understands the importance of keeping your health information private. We are required by law
to maintain the privacy of health information that identifies you or can be used to identify you.
We are also required to provide you with this notice of our privacy practices, our legal duties and
your rights concerning your health information. We are required to abide by the terms of this
notice currently in effect. We may modify or change our privacy practices described in this notice
from time to time, particularly as new laws and regulations become effective. Any changes will
be effective for all the health information that we maintain, even information in existence before
the change. If we materially modify our privacy practices, you may obtain a revised copy of this
notice by contacting us using the information listed at the end of this notice, or by accessing our
website at www.gobio.com/patients..
USES AND DISCLOSURES OF YOUR HEALTH INFORMATION
USES AND DISCLOSURES THAT MAY BE MADE WITHOUT YOUR AUTHORIZATION OR
OPPORTUNITY TO OBJECT
We may use and disclose your health information, without your authorization, in the following
ways:
Treatment:
We may use and disclose your health information to provide, coordinate or manage
your treatment. For example, we may disclose your health information to a provider who requests
this information to treat you.
Payment:
We may use and disclose your health information to bill and get payment for health
services we provide to you. For example, we may disclose your health information to your health
insurance plan to obtain payment for services provided to you.
Health Care Operations:
We may use and disclose your health information in order to support
our business activities. For example, we may use your health information to conduct quality
improvement activities, to engage in care coordination and case management, to conduct
business management and general administrative activities, and other similar activities.
Health & Wellness Information:
We may use your health information to contact you with