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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 nancially 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. I will also be asked to give BioTelemetry and its
subsidiaries permission to use my monitoring data, without my identity, in clinical research and case
studies. This is an option and not required to continue to receive monitoring services.
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 identies 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 information
about health related services or appointment reminders. If you do not wish to receive this type of
information, you may request to opt-out of receiving this information by sending an email to privacy@
biotelinc.com or calling the phone number provided at the end of this notice.
Research; Death; Organ Donation: We may use or disclose your health information for research
purposes in limited circumstances. We may disclose your health information to a coroner, medical
examiner, funeral director or organ procurement organization for certain purposes.
Public Health and Safety: We may use and disclose your health information to the extent necessary
to avert a serious and imminent threat to your health or safety or the health or safety of others. We
may disclose your health information to appropriate authorities if we reasonably believe that you are a
possible victim of abuse, neglect, domestic violence or other crimes.
Required by Law: We will use or disclose your health information when we are required to do so by law.
Process and Proceedings: We may disclose your health information in response to a court or
administrative order, subpoena, discovery request or other lawful process.
Law Enforcement: We may disclose your health information, so long as applicable legal requirements
are met, to a law enforcement ofcial, such as for providing information to the police
about the victim of a crime.
Inmates: We may disclose your health information if you are an inmate of a correctional institution and
we created or received your health information in the course of providing care to you.
Military and National Security: We may disclose your health information to military authorities if you are
a member of the Armed Forces. We may disclose your health information to authorized federal ofcials
for lawful intelligence, counterintelligence and other national security activities.
Workers’ Compensation: We may disclose your health information as authorized by and to the extent
necessary to comply with laws relating to workers' compensation or other similar programs, established
by law, that provide benets for work-related injuries or illness without regard to fault.
Business Associates: We may disclose your health information to persons who perform functions,
activities or services to us or on our behalf that require the use or disclosure of your health information.
To protect your health information, we require the business associate to appropriately safeguard your
information.
To You: We will disclose your health information to you, as described in the Individual Rights section of
this notice.
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