Please fill out the following form to register for the Digital Pathology Portal.
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UPP-Pathology Digital Pathology Consulting Services Terms and Conditions and Provider Request Form
By checking the box and signing the Consultation Request Form below, Provider affirms that he or she has read, understands and agrees to all of the terms and conditions of this Agreement.
UPP-PATHOLOGY is the Pathology Department of the University of Pittsburgh Physicians, a Pennsylvania non-profit corporation that is affiliated with UPMC, and that employs individuals who are duly qualified and licensed physicians in the Commonwealth of Pennsylvania, fully qualified for practicing the specialty of pathology or in a related area of medicine.
By entering into this Agreement, Provider seeks to retain, as independent contractors, UPP-PATHOLOGY to provide online telepathology second opinion consultation medical services (the "Services").
Provider hereby retains UPP-PATHOLOGY to perform the Services for Provider in accordance with all applicable laws, rules, regulations and directives of all applicable federal, state and other government and regulatory authorities, including all licensing agencies, and on the terms and conditions hereinafter set forth. Provider agrees and acknowledges that UPP-PATHOLOGY shall be providing consultation services only, that Provider shall be the only party under this Agreement to provide clinical services to his or her patients in connection with any of the Services provided by UPP-PATHOLOGY, and that the Provider shall be solely responsible for all patient care and treatment decisions and shall be free to accept or reject any online second opinion consultation services and/or advice provided by UPP-PATHOLOGY.
Provider agrees that he or she shall be solely responsible for obtaining all patient consents and/or authorizations necessary to utilize the Services of UPP-PATHOLOGY, if any.
In order for UPP-PATHOLOGY to provide the Services, Provider shall provide to UPP-PATHOLOGY all pertinent clinical information, samples, slides, etc. for the patients, related medical tests and records and any necessary patient consent form via the Digital Pathology Consulting Service or facsimile.
Once UPP-PATHOLOGY has received complete digital pathology image(s) via internet connection and uploading, and has received all related pertinent patient information from Provider via the registration module of this Digital Pathology Consulting Service that successfully matches the patient who is the subject of the specimen, UPP-PATHOLOGY shall use its best efforts to analyze such specimen and provide Provider, via e-mail, with a professional preliminary consultative interpretation report of each specimen within 2 days/48 hours of UPP-PATHOLOGY’s receipt of each specimen. UPP-PATHOLOGY shall not be responsible for providing Provider with a professional preliminary consultative report for any complete pathology specimen where the specimen does not successfully match the related pertinent patient information sent to UPP-PATHOLOGY by Provider.
By requesting a second opinion pursuant to this website, Provider acknowledges and agrees that the diagnosis that Provider will receive from UPP-PATHOLOGY is limited and provisional. UPP-PATHOLOGY’s second opinion is not intended as a separate diagnosis, nor to replace a full medical evaluation by, or a face-to-face visit with, the Provider. UPP-PATHOLOGY does not have important information that is usually obtained through a physical examination and face-to-face visit. Provider understands and agrees that if Provider elects to use UPP-PATHOLOGY’s second opinion, Provider will use it solely for the limited purpose of providing Provider with additional information from which he or she can decide upon the appropriate diagnosis and treatment of a medical condition of one of Provider’s patients, and may not be used for any other purpose.
UPP-PATHOLOGY’s Online Consultation Services are NOT available to Providers with respect to Providers’ patients that are residents of, or who have current mailing addresses in, the following states: Iowa, Louisiana, and North Dakota. By signing below, Provider affirms that the patient about whom Provider is requesting consultation services from UPP-PATHOLOGY is NOT a resident of, and does not have a current mailing address in any of those states.
UPP-PATHOLOGY and Provider agree to comply with all applicable federal, state and local laws and regulations governing the security and privacy of individually identifiable health information, including without limitation the federal Health Insurance Portability and Accountability Act of 1996, and its implementing regulations, as applicable and all as may be periodically revised or amended from time to time as amended from time to time, ("HIPAA"). Unless otherwise permitted by applicable law, each party to this Agreement will not use or disclose certain confidential, proprietary, and nonpublic financial and other information concerning patients ("Protected Health Information") in violation of the HIPAA requirements. Each Party agrees to use their best efforts to comply with HIPAA in all respects, including the implementation of all necessary safeguards to prevent such disclosure and the assurance that any subcontractors or agents to whom either party provided Protected Health Information agree to the same restrictions and conditions imposed on the parties hereto under HIPAA.
The cost of a UPP-PATHOLOGY online Second Opinion Consultation will range from $150 to $500 depending on the complexity of the case. Payment is due at the time the request is made or within twenty (20) days of Provider’s receipt of an invoice from UPP-PATHOLOGY.
This Agreement shall be governed by, and construed in accordance with, the laws of the Commonwealth of Pennsylvania without regard to its conflicts of laws rules. Any dispute shall be exclusively brought in the state or federal courts located in Pittsburgh, Allegheny County, Pennsylvania.
* I have read, understand, and agree to all of the Terms and Conditions of this
UPP-PATHOLOGY Digital Pathology Consulting Service Agreement.
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