Certifications and Authorizations
Review these materials before signing the InTandem Patient Authorizations.
Questions? Contact InTandem Support during regular business hours by calling the number below:
Review the following:
- Patient Certifications
- Authorization to Share Health Information
If you agree, check the box on the Patient Enrollment Form. Also, sign and date the document.
Contact InTandem Support via phone with any questions.
Patient Certifications
- I certify that the personal information that I provide to InTandem Support, the support program from MedRhythms, is true and complete.
- I certify that all plans and programs through which I obtain healthcare coverage are listed. I further certify that I am not insured for or am rendered uninsured through the payer denial of applicable product, and that I am a resident of the United States.
- I understand that changes in my insurance provider, insurance coverage, or financial situation may affect my eligibility for certain InTandem Support patient services, and I agree to immediately notify my Patient Coordinator at 1 (855) 900-7837 of these changes (i.e., if I start to receive benefits from a federal or state government funded program, such as Medicare or Medicaid).
- I understand that I may refuse to sign this Authorization. I further understand that my/my legal representee’s treatment (including with a MedRhythms Product), payment for treatment, insurance enrollment or eligibility for insurance benefits are not conditioned upon my agreement to sign this Authorization.
- MedRhythms does not guarantee coverage or reimbursement for applicable products. Coverage and reimbursement decisions are made by insurance companies following the receipt of claims.
- I acknowledge and agree to the MedRhythms, Inc. Terms of Service. I also understand that I can access the Terms of Service at medrhythms.com or may request them by writing:
InTandem Support
183 Middle St, Suite 300
Portland, ME 04101
Authorization to Share Health Information
1. What personal health information will be gathered and disclosed?
My personal health information will be disclosed, including:
- Information in the enrollment package
- My contact information and date of birth
- Insurance benefit information
- Health records and information, including my diagnosis and therapy prescribed to me
2. Who will disclose, receive and use the information?
This authorization permits my health care team (which includes my health care providers, health plans, and health insurers that provide service to me, as well as other people that I may authorize) to disclose my personal information to InTandem Support, a service of MedRhythms, Inc., and its “Administrators.”
InTandem Support and its Administrators may also share my information with other health care providers and health insurers to determine if I am eligible for, or enrolled in, another plan or program, and to administer InTandem Support. I understand that InTandem Support does not permit my personal information to be used by its Administrators for their own separate marketing purposes.
3. What is the purpose for the use and disclosure?
My personal information will be used by and shared with the persons and organizations described in this authorization in order to:
- Provide me with personalized services through programs that cover education, insurance questions, and treatment support.
- Contact me, my health care team and my caregiver about InTandem Support and the offerings that are available.
- Contact other health care providers and insurers about my medical care and to determine if I am eligible for, or enrolled in, another plan or Program.
4. What does providing my mailing address, email, and/or telephone number indicate?
By providing my mailing address, email, and/or telephone number, I:
- Agree to be contacted by InTandem Support and others on its behalf by mail, email, telephone calls, and text messages (if authorized) at the numbers and addresses provided on this form for all purposes described in this Patient Authorization.
- Confirm I am the subscriber for the telephone number(s) provided, I am the authorized user for the email address(es) provided, and agreed to notify InTandem Support promptly if any of my number(s) or email address(es) change in the future.
5. When will this authorization expire?
This authorization will be effective for five years unless it expires earlier by law or I cancel it in writing. I may cancel this authorization by writing to:
InTandem Support
183 Middle Street, Suite 300
Portland, ME 04101
For additional information about canceling this authorization, I can call my Patient Coordinator at: 1 (855) 900-7837
If I cancel this authorization, I will no longer be able to participate in InTandem Support.
InTandem Support will stop using or disclosing my information for the purposes listed in this consent as necessary to end my participation or as required or allowed by law. This cancellation will not invalidate any reliance on the usage or disclosure of my information prior to my cancellation. I understand there may be a delay for cancellation to take effect.
6. Notices
Once my health information has been disclosed to MedRhythms and its authorized agents and assignees (“Administrators”), I understand that the Health Insurance Portability and Accountability Act (HIPAA) may no longer restrict its use or disclosure, in certain instances.
However, I understand that MedRhythms and its Administrators authorized to receive my health information pursuant to this authorization agree to protect my health information by using and disclosing it only for purposes set forth in this authorization or as required by law and regulations.
I further understand that I may refuse to sign this authorization and that if I refuse, my eligibility for health plan benefits and treatment by my health care providers will not change, but I will not have access to InTandem Support.
I have a right to receive a copy of this authorization after I have signed it by sending a written request to:
InTandem Support
183 Middle Street, Suite 300
Portland, ME 04101
I may call my Patient Coordinator at: 1 (855) 900-7837
My treatment (including with a MedRhythms product), insurance enrollment, and eligibility for insurance benefits are not conditioned upon my signing this authorization.
MedRhythms' Policies
MedRhythms is the company that makes InTandem.
To learn more about MedRhythms product development, visit the company website. Review the MedRhythms’ Terms of Service and Privacy Policy to better understand the services provided.
MedRhythms Authorization for Marketing & Other Communications
Consent to be contacted by MedRhythms
I authorize MedRhythms to contact me by mail, email, or telephone call (if authorized) for marketing purposes or otherwise provide me with information about MedRhythms products, services, and programs or other topics of interest, conduct market research or otherwise ask me about me or my legal representee’s experience with or thoughts about such topics.
I understand and agree that any information that I provide may be used by MedRhythms to help develop new products, services, and programs.
Note that MedRhythms will not sell or transfer your personal data to any unrelated third party for marketing purposes without your express permission.
I have reviewed MedRhythms’ Privacy Policy.
Cancelling & Expiration
I may cancel this Marketing Authorization at any time by sending a written request to:
InTandem Support
183 Middle Street, Suite 300
Portland, ME 04101
Canceling this Marketing Authorization will end my consent to receive marketing information from InTandem Support; it will not affect my ability to receive treatment, payment for treatment, or my eligibility for health insurance.
This Marketing Authorization expires after five (5) years, or such shorter timeframe required by applicable law, from the day I sign it as indicated by the date next to my signature unless otherwise canceled earlier as set forth above. I understand I have a right to receive a copy of this form.