consent to telehealth treatment

Consent to Telehealth Treatment

Modern Health is a comprehensive digital mental health and wellbeing platform that includes a clinically integrated network of mental health and wellness providers offering coordinated care in a digital setting in order to give people the tools they need to build resilience, proactively engage in their mental health, and get the support they need, when they need it.
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By using the app, you have selected one of Modern Health’s affiliated Practices, as defined below, as your mental health and wellness provider for you and, if applicable, your minor children who you register for services through the app. You consent to receiving access to asynchronous digital programs and tools in the app that you may choose to use without ever matching with a licensed provider and/or certified coach, as well as to the services, examinations, and treatment performed and ordered by your licensed providers and/or certified coaches furnished by the Practice. You understand that your mental health and wellness care may be provided by a variety of different types of digital programs and providers, including psychiatrists, therapists, and coaches. You acknowledge that mental health care is not an exact science and that Modern Health does not make any guarantees regarding the services provided through the app or Practice, and you elect to receive services with full understanding of this information. You have the right to withdraw this consent at any time by sending written notice including your name and address through electronic mail to Practice at: legal@modernhealth.com. Your withdrawal will be effective upon Practice’s receipt of your written notice, except that your withdrawal will not have any effect on any action taken by the Provider in reliance on this consent before Practice received your written notice of withdrawal. Please be aware, however, that withdrawal of this consent may result in the termination of your access to certain services via the Modern Health App and your ability to receive services from Modern Health and Practice. If registering for services for your minor children, you consent to the collection and disclosure of personal information of such minor children for any lawful purpose.
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“Practice” shall mean Modern Health Arizona P.L.L.C. if you reside in and are physically located in one of the following states: Alabama, Alaska, Arizona, Arkansas, Colorado, Connecticut, Delaware, Florida, Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Mexico, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, Washington, Washington, D.C., West Virginia, Wisconsin, Wyoming.

“Practice” shall mean Modern Health New Jersey L.L.C. if you reside in and are physically located in New Jersey.

“Practice” shall mean Hopkins Telemedicine PLLC if you reside in and are physically located in New York.

“Practice” shall mean Modern Health California, P.C. if you reside in and are physically located in California.

Telehealth Treatment

Practice, its affiliated health care providers, or other members of your care team, including coaches (each, a “Provider”), may arrange for you to connect with Providers and/or provide you with professional services using asynchronous and/or synchronous telehealth technologies (“Telehealth Technology”). If you have questions about use of the Telehealth Technology itself and whether it is appropriate for your condition, the risks associated with using the Telehealth Technology, or the Provider’s credentials and professional background, please ask your Provider. In exchange for your use of the Telehealth Technology to receive care, you acknowledge and agree to the following terms and conditions of this informed consent:

Use of Telehealth Technology. You understand and agree that:

There are many benefits, but also risks associated with receiving care via Telehealth Technology. Benefits include convenience, increased access, and the ability to receive care in your home. Risks are outlined in Section 2 below.

The anticipated response time for electronic communications submitted through the Telehealth Technology varies and you accept any risk associated with the response time, including a delay in obtaining medical care.

The Provider will decide, in his or her sole discretion, whether it is appropriate to treat your condition using the Telehealth Technology. The Provider may request that you stop receiving care via Telehealth Technology and instead receive in-person care if the Provider deems appropriate.

Services provided through Telehealth Technology may include behavioral health services, including tele-psychiatry, and you expressly agree to receive such services through Telehealth Technology.

If you are a parent or legal guardian of a minor that is seeking to receive mental health treatment through Telehealth Technology, you agree that (1) you are providing this Consent on behalf of your minor child, and (2) you will verify your identity before any services are delivered to your minor child.

Services provided through Telehealth Technology may involve electronic communication of your personal medical information to Providers that may be located in other areas, including out of state.

Your Provider will protect the privacy and security of any personal medical information transmitted through Telehealth Technology in accordance with federal, state, and other applicable law.

You have the right to request copies of your medical records, which may be provided electronically or in hard copy format at reasonable cost of preparation, shipping and delivery.

No warranty or guarantee has been made to you concerning any particular result related to your condition or diagnosis.

Risks Associated with Use of Telehealth Technology. You understand that use of the Telehealth Technology has risks associated with it, such as (1) information that you transmit through the Telehealth Technology may be insufficient to allow for appropriate decision-making by the Provider; (2) failures of equipment (e.g., servers, devices) or infrastructure (e.g., communications lines, power supply, software failures) may cause interruptions and delays in the provision of care and treatment, or loss of information; and (3) in rare events, security protocols could fail, causing unauthorized access to your health information. You acknowledge that, although Practice and its telehealth technology vendor strive to prevent unauthorized access to information about you through encryption of information transmitted by the Telehealth Technology and other security measures, Practice and its vendor cannot guarantee that your use of the Telehealth Technology and the information will be private or secure, and you consent to this risk. You understand and consent to the risks associated with your use of the Telehealth Technology.

Group Support. If you and a Provider decide to engage in group or couples therapy or any other group wellness or health offerings (collectively “Group Support”), you understand that information discussed in Group Support is for therapeutic and/or support purposes and is not intended for use in any legal proceedings involving Group Support participants. You agree not to subpoena the Provider to testify for or against other Group Support participants or provide records in court actions against other Group Support participants. You understand that anything any Group Support participant tells the Provider individually, whether on the phone or otherwise, may at the Provider’s discretion be shared with the other Group Support participants. You agree to share responsibility with the Provider for the process, including goal setting and termination.

Accuracy of Information Submitted to the Provider. You acknowledge and agree that you are solely responsible for ensuring that the information submitted by you through the Telehealth Technology is accurate, complete and current at all times when you use the Telehealth Technology. You understand that the Provider will rely on this information to provide services to you.

Release and Waiver. You acknowledge and agree to limit, disclaim, and release Practice and Modern Health from liability in connection with the use of Telehealth Technology.

Expenses; Financial Agreement. You understand and agree that you may be responsible for the cost of certain professional fees associated with your use of the Telehealth Technology and the cost of any medications or supplies prescribed by the Provider, if applicable. You acknowledge and agree that you are financially responsible for the services rendered to you in accordance with Modern Heath and the Practice’s regular rates and terms. You acknowledge and agree that you accept full financial responsibility for all charges billed and guarantee to pay all such charges. You acknowledge and agree that the Practice may contract with your employer or various health care plans and that any charges not paid by your employer, health plan, health insurance benefits, or otherwise not covered by your health insurance (including, but not limited to, any co-payments, co-insurance, and deductibles) are your financial responsibility. All accounts are due and payable upon presentation of a statement. Co-payments, if any, are due at the time of your appointment and prior to seeing your Provider. Please note that Practice may be an out-of-network provider for some insurance companies and, if applicable, you will incur a higher out-of-pocket expense when utilizing Practice’s services.

Other Legal Terms. This consent cannot be amended by Practice except in writing and with your consent. If any provision is or becomes unenforceable or invalid, the other provisions will continue with the same effect.

Right to Revoke. You have the right to withhold or withdraw your consent to the use of Telehealth Technologies in the course of your care at any time, without affecting your right to future care or treatment. You may suspend or terminate access to the services at any time for any reason or for no reason in accordance with this Section 8. You understand that you can revoke this consent by sending written notice using electronic mail to Practice at: legal@modernhealth.com (“Revocation”). You agree that your Revocation must contain your name and your address. You also understand that your Revocation means that you are not permitted to receive care using Telehealth Technology. Your Revocation will be effective upon Practice’s receipt of your written notice, except that your Revocation will not have any effect on any action taken by the Provider in reliance on this consent before Practice received your written notice of Revocation.