I understand that by checking “I Agree” I give my informed consent to the rendering of professional mental health care services via the UpLift Health Technologies, Inc. (“UpLift”) platform, which includes, without limitation, receiving remote care via telephone, video or other electronic means, including asynchronous technology, by the mental health care providers that treat me through the UpLift platform including, but not limited to, providers that are employed by or contracted with UpLift Behavioral Health PC and UpLift Behavioral Health NJ, PC (collectively the “Behavioral Health Professional Entities”) or in-person care at the office of one of the Behavioral Health Professional Entities mental health care providers (“Behavioral Health Locations”). Care may include, but is not limited to, assessing, diagnosing, and treating a wide range of mental health illnesses with professional mental health services and other follow-up care (which may include prescribing medications), as needed.
For telehealth treatment, I understand that using the UpLift platform sometimes involves the delivery of mental health services by a provider that is located at a different site by using electronic information and communication technologies. Electronic communication technologies, including audio, video, and/or data communications may be used between the patient and the mental health care provider to transmit data including, but not limited to, personal health information, photographs, videos, prescriptions/orders and medical records. I understand that the remote services may be provided by new technologies not included in this consent. I will be informed of all parties that are present during a remote service.
I understand that a mental health care provider has the right to determine that my needs are not appropriate for remote treatment and, as a result, I may need to seek alternative treatment methods (e.g., such as receiving in-person care with one of the Behavioral Health Locations). Receiving remote treatment is voluntary and if I decide to stop receiving remote treatment, that will not impact my right to receive mental health care services in the future.
For treatment by telehealth or in-person, I understand that the laws that protect privacy and confidentiality of my medical information also apply to the services I receive via the UpLift platform and at Behavioral Health Locations. I understand that any information shared in any therapy process is confidential and may not be shared without prior consent, except in certain circumstances such as suspected abuse, threat to self or others, or as required by law.
I understand that mental healthcare, including but not limited to the practices of psychiatry, psychology and mental health counseling, is not an exact science and that diagnosis and treatment involves benefits and risks. There may be risks to my physical or mental well-being.
If I elect to receive remote services, I understand that there are specific risks and benefits to receiving services remotely.
Benefits of remote services include the following:
Remote care is more accessible and allows you to receive care without the wait and at a time and place that is convenient for you.
Remote care can improve communication between you and your provider.
Remote care is subject to the same privacy protections as in-person visits.
Risks of remote services include the following:
A remote mental health care exam is not a complete exam and does not allow for physical assessment and in some cases could lead to an incorrect diagnosis or be insufficient for a provider affiliated with UpLift to perform services for you.
The transmission of protected health information via the internet could result in a data breach, subjecting your health information to exposure.
Technological glitches can disrupt internet connections and cause a delay to your session with the provider.
Do not use this service if you are experiencing a medical emergency, if you are thinking about suicide or are considering actions that may cause harm to you or others, or if your current healthcare provider has advised against your participation. Regardless of whether you receive telehealth services or in-person care, in the event of an emergency, call 911 or a crisis hotline or proceed to the nearest emergency room. This is not an emergency service.
Services provided via the UpLift platform or at Behavioral Health Locations are not intended to replace your primary care medical services. The UpLift platform and the Behavioral Health Locations do not provide crisis services to the general public, or mental health services for individuals under the age of 13.
Costs and Reimbursements
I will receive information regarding fees including expectations for payment, insurance information and cancellation fees.
Patient Acknowledgment and Agreement
I hereby acknowledge that I am aware of all potential risks associated with receiving services from UpLift, including any remote mental health care services, and mental health care services at the Behavioral Health Locations. I acknowledge that no guarantees have been made to me regarding the result of a diagnosis or treatment provided to me by providers affiliated with UpLift. As with any other health care and/or mental health services, some individuals do not respond to treatment.
I have disclosed all relevant background and history, any known health conditions that my mental health care provider has requested I disclose in advance of receiving services and, if applicable, allergies and medications I am taking, including herbal medications/supplements.
I authorize the UpLift affiliated provider to share information pertaining to my treatment (including any remote treatment) with other individuals for treatment, payment and health care operations purposes including, without limitation, my primary care provider. I authorize any affiliated provider(s) to release information pertaining to my remote treatment to UpLift and its affiliates.
I understand that the terms herein are contractual and not a mere recital and that I electronically sign this document as my own free act and void of any coercion. The permissions granted herein shall begin on the date listed below and shall remain effective until terminated by me. I understand that I have the right to withhold or withdraw my consent at any time by submitting a request via email to email@example.com.
If I am a patient residing in Virginia, I agree to hold harmless Uplift and its affiliates for information lost due to any technical failure of the UpLift platform.
I understand that clicking “I Agree” constitutes a legal signature and verifies that I that I have read all of the information contained in this Consent Form, I understand the risks and benefits of receiving services (including remote services) by providers affiliated with the UpLift platform and the Behavioral Health Locations and the ability to withdraw treatment at any time (and understand the possible risks associated with withdrawing) and I have had an opportunity to ask questions about anything I have not understood up to this point.
Notice of Privacy Practices
The Company disseminates and maintains a Notice of Privacy Practices (“Privacy Notice” or “Notice”) that clearly states the manner in which it may use and disclose an individual’s protected health information (“PHI”), and provides adequate notice of an individual’s rights and Company’s legal duties with respect to PHI. Individuals have a right to request and receive a paper copy of the Privacy Notice at any time.
Privacy Notice Responsiblity
The Privacy Officer is responsible for developing, reviewing, revising, updating and disseminating the Company’s Privacy Notice to ensure that it conforms to these Policies and Procedures.
The Privacy Notice will be in plain language and include the content requirements set forth in 45 C.F.R. § 164.520.
DISSEMINATION OF NOTICE
Time to Notify Individuals
Notification. The Company must distribute the “Notice of Privacy Practices” to an individual prior to the individual’s first receipt of health care services or, in emergency situations, as soon as reasonably practicable.
Availability of Privacy Notice
Electronic Notice. The Company may provide Notice to an individual by e-mail if the individual agrees to such Notice. If the Company becomes aware that e-mail transmission has failed, a paper copy of the Notice must be provided to the individual. An individual receiving e-mail Notice always maintains the right to obtain a paper copy of Notice from the Company upon request.
Paper Copy of Notice. Individuals have a right to a paper copy of the Privacy Notice, even if they have previously agreed to receive the Privacy Notice electronically. Individuals may receive a copy of the Privacy Notice by: Email Request. An individual can submit a request for Notice to: firstname.lastname@example.org
Availability on Website. To the extent the Company maintains a website, the Privacy Notice must be placed and maintained on the Company’s web site and be available electronically through the website.
3. ACKNOWLEDGEMENT OF RECEIPT
Acknowledgement of Paper Copy of Notice
Each paper copy of the Privacy Notice given to an individual shall have attached to it a cover page entitled Patient Acknowledgement of Receipt of Notice of Privacy Practices, which the individual will be asked to date and sign at the time the individual is given the Privacy Notice. If the individual is unable or unwilling to date and sign the acknowledgement form, Company employees should document in writing on the face of the acknowledgement form the reason for the inability or refusal of the individual to sign. Such reason could simply be, e.g., that the individual refused to sign after being requested to do so. Company’s duty under the law is only to make a good faith effort to obtain the acknowledgement of receipt. If the individual does not want to sign the acknowledgement form, he or she is not required to do so.
Acknowledgement of Electronic Notice
If an individual wishes to receive the Notice electronically, the system should request the patient to acknowledge receipt electronically.
The Company will retain copies of the Privacy Notices issued by it for six (6) years following their last effective date, in accordance with Company’s record retention policy.
Clicking “I Agree” constitutes a legal signature and acknowledgment of this notice and verifies that I have read all of the information contained in this Notice of Privacy Practices.
Patient Financial Responsibility Agreement
I understand that by signing this Patient Financial Responsibility Agreement, I consent to the terms and conditions set forth below regarding the professional therapy services I receive from providers using the UpLift Health Technologies, Inc. and UpLift Behavioral Health PC (“UpLift”) platform.
I acknowledge and agree as follows:
I assume full responsibility, and agree to pay all costs, charges, co-payments and expenses of every kind and description for all services provided to me by UpLift and my provider using the UpLift platform.
Each bill for any charges from UpLift or the providers using the UpLift platform will be due upon completion of your session.
UpLift accepts most major credit cards and payments via ACH.
If I have a health insurance policy, I have carefully read the section in my health insurance policy that describes mental health services. If I have questions about my coverage, I will call the plan administrator to ask questions and clarify my benefits. I am responsible for knowing what my insurance plan will and will not cover.
If I have a health insurance policy, I have provided UpLift with the most correct and updated information about my insurance. If I provide UpLift with incorrect information about my insurance, I will be fully responsible for any charges for the cost of my therapy services provided through the UpLift platform.
I may incur additional charges at the discretion of UpLift, including without limitation charges for credit card payment processing fees, missed appointments without notice per UpLift’s policies, charges for extensive phone consultations and/or after-hours calls, and any costs associated with the collection of my unpaid balances.
I authorize UpLift and the providers using the UpLift platform to release my medical and other information acquired in the course of my examination and/or treatment to the necessary insurance companies, other third party payors, and/or other physicians or healthcare entities required to participate in my care.
I authorize assignment of financial benefits directly to UpLift and the providers using the UpLift platform for any services rendered as allowable under standard insurance and other third-party payor contracts. I understand I am financially responsible for charges not covered by this assignment.
I understand that the terms herein are contractual and not a mere recital and that I sign this document as my own free act and void of any coercion.
I understand that clicking “I Agree” constitutes a legal signature and verifies that I have read all of the information contained in this Patient Financial Responsibility Agreement.