Location: 106 19th St S Suite 106 Sartell, MN 56377

Terms and Conditions

Specialized Treatments. Personalized Care. Faster Results.

Below are our terms of service pertaining to the use of our online consultation platform.

Protected Health Information Agreement

Refine Acne Clinics, PLLC takes the responsibility of using private information of its patients seriously.

Refine Acne Clinics, PLLC utilizes a platform called Refine Acne Clinics’ Online Consultation (“RACOC”). This platform requires the Patient to submit Protected Health Information (“PHI”) that is subject to all federal and state laws regarding PHI, including, but not limited to HIPAA. Refine Acne Clinics, PLLC will abide all state and federal laws when dealing with PHI. A copy of Refine Acne Clinics, PLLC’s PHI Privacy Policy is available by request by writing Refine Acne Clinics, PLLC at:

161 19th Street South

Suite 106

Sartell, MN 56377

I understand there is a risk of technical failure during the RACOC encounter beyond the control of Refine Acne Clinics, PLLC. I agree to hold harmless Refine Acne Clinics, PLLC for delays in evaluation or for information lost due to such technical failures.

By checking the Box “Accept” I hereby state that I am the patient or patient’s legal guardian and I have read, understood, and agree to the terms Refine Acne PLLC’s Protected Health Information Agreement.

 

 

Refine Acne Clinics, PLLC Online Consultation Payment Agreement

 

The Patient agrees to allow Refine Acne Clinics, PLLC to securely charge a credit/debit card, referred to as the “payment method”. The Patient authorizes the payment method to be used for the Refine Acne Clinics’ Online Consultation (“RACOC”). The Patient represents and warrants that:

(a) The Patient, or the Patient’s legal guardian, is the person in whose name the credit/debit card was issued and the Patient is authorized to make a purchase or other transaction with the relevant credit/debit card and information.

(b) The Patient will pay the charges incurred in the online consultation, less any applicable coupon codes or discounts.

(c) Any credit/debit card information the Patient supplies is true, complete, and free from error.

(d) No refunds will be given for consults at any time, unless the reviewing physician from Refine Acne Clinics, PLLC has determined the patient needs to be examined in a physician’s physical office.  Under no circumstances will a refund be issued if the patient is unhappy with the result of the online consultation.

 

The Patient agrees that all services rendered by Refine Acne Clinics, PLLC via the RACOC technology is private-pay and no payment from insurance carriers will be accepted.

If Refine Acne Clinics, PLLC is unable to secure funds from the Patient’s debit/credit card(s) for any reason, including, but not limited to, insufficient funds in the debit/credit card or insufficient or inaccurate information provided by the Patient when submitting electronic payment, Refine Acne Clinics, PLLC may undertake further collection action, including application of fees to the extent permitted by law.

The Patient has the right to revoke this authorization by notifying Refine Acne Clinics, PLLC at least eighteen (18) days prior to the scheduled payment date. The Patient understands and acknowledges that services may be canceled or withheld if the Patient revokes this authorization and that Patient is still responsible for all charges incurred by the Patient or otherwise owed to Refine Acne Clinics, PLLC. This authorization will remain in full force and effect until revoked by the Patient or Refine Acne Clinics, PLLC.

The Patient acknowledges and agrees he or she will not dispute the payment with the credit/debit card company, provided the transactions correspond to the terms indicated in this online consultation payment agreement.

By checking the Box “Accept” I hereby state that I, the Patient or the Patient’s legal guardian, have read, understood, and agree to the terms of this document and I authorize Refine Acne Clinics, PLLC to charge/debit/withdraw funds from my account as stated above.

 

 

Refine Acne Clinics’ Online Consultation Consent

Refine Acne Clinics’ Online Consultation (“RACOC”) involves the use of digital communications to enable dermatology providers to review individual patient medical information, also known as Protected Health Information, for the purpose of evaluating and treating acne.

RACOC services also include e-prescribing, prescription refills, and non-clinical services, such as educational content. Refine Acne Clinics, PLLC providers may include dermatologists, nurse practitioners, and physician assistants. The information may be used for diagnosis, therapy, follow-up and/or education, and may include any combination of the following: (1) patient medical records; (2) medical images; and (3) store and forward electronic communications.

Electronic systems used will incorporate physical and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

Refine Acne Clinics, PLLC does not take responsibility for your normal medical care. Please consult with your primary doctor for other conditions not related to acne. Refine Acne Clinics, PLLC does not document or contain any documentation regarding your overall medical condition besides the brief questions used in the RACOC.

Anticipated Benefits:

  • Obtaining expertise of a dermatologist
  • Improved access to acne care by enabling you to remain outside of your doctor’s office while the provider reviews your case.
  • More efficient acne evaluation and management.

Possible Risks:

  • Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment and technologies.
  • In rare events, the provider may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled RACOC consult or an in-person meeting with your provider.
  • In very rare events, security protocols could fail, causing a breach of privacy of personal medical information.
  • In rare events, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors.

By checking the box “Accept”, you acknowledge that you understand and agree with the following:

I hereby consent to receive Refine Acne Clinics, PLLC’s services via RACOC technology. I also understand it is up to the Refine Acne Clinics, PLLC provider to determine whether or not my needs are appropriate for the RACOC technology and that the provider may determine an in-office visit is necessary.

  1. I understand that I may expect the anticipated benefits from the use of RACOC in my care, but that no results can be guaranteed or assured.
  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 Refine Acne Clinics, PLLC will take steps to make sure that my health information is not seen by anyone who should not see it.
  3. I understand that I have the right to withhold or withdraw my consent to the use of RACOC 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 access to the service 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 911 immediately and that the Refine Acne Clinics, PLLC acne specialists are not able to connect me directly to any local emergency services.
  4. I understand images of me will be captured and stored electronically. I understand that these recordings may be later viewed and used for purposes of evaluation and training, which may include Refine Acne Clinics, PLLC non-physician personnel, and students. I understand and consent to the use of these images for the RACOC consultation and, potentially, evaluation, education, and training. I understand that sessions may also be monitored for training, audit, support, or other reasons associated with my care.
  5. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Persons may be present during the consultation other than the Refine Acne Clinics, PLLC provider in order to operate the RACOC technologies. I further understand that I will be informed of their presence in the consultation 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 the RACOC examination; and/or (3) terminate the consultation at any time.
  6. I understand that if I participate in an online consultation, that I have the right to request a copy of my medical records which will be provided to me at a reasonable cost of preparation, shipping, and delivery.
  7. I understand that in the event of any problem with the website or related services, I agree that my sole remedy is to cease using the website or terminate access to the service. Under no circumstances will Refine Acne Clinics, PLLC or any Refine Acne Clinics, PLLC subsidiary or affiliate be liable in any way for the use of the RACOC services, including but not limited to, any errors or omissions in content or infringement by any content on the website of any intellectual property rights or other rights of third parties, or for any losses or damages of any kind arising directly or indirectly out of the use of, inability to use, or the results of use of the website. I agree that I will not hold Refine Acne Clinics, PLLC, and its affiliates liable for any punitive, consequential, incidental, indirect or other special damages (including, without limitation, personal injury, lost profits, business interruption, loss of programs or other data on my computer or otherwise) arising from, or in connection with your use of the website whether under negligence, a breach of contract,  strict liability, malpractice or otherwise, even if we or they have been advised of the possibility of such damages.
  8. I understand that Refine Acne Clinics, PLLC makes no representation that materials on this website are appropriate or available for use in any other location. I understand that if I access these services from a location outside of the State of Minnesota, that I do so at my own risk and initiative and that I am ultimately responsible for compliance with any laws or regulations associated with my use.

Consent of Patient

I have read this document carefully, and understand the risks and benefits of the RACOC consultation and have had my questions regarding the procedure explained and I hereby give my informed consent to participate in a RACOC consultation under the terms described herein.

By checking the Box containing “Accept” I hereby state that I have read, understood, and agree to the terms of this document.