I understand that by checking “I Agree” I give my informed consent to the rendering of professional therapy services via the UpLift Health Technologies, Inc. and UpLift Behavioral Health PC (“UpLift”) platform, which includes without limitation receiving remote care via telephone, video or other electronic means, including asynchronous technology, by the provider that treats me through the UpLift Health Technologies, Inc. and UpLift Behavioral Health PC (“UpLift”) platform. Care may include, but is not limited to, assessing, diagnosing, and treating a wide range of mental health illnesses with professional therapy services and other evidence-based practices, as needed.
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 me, as client, and the provider to transmit data including, but not limited to, my 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 understand that the laws that protect privacy and confidentiality of my medical information also apply to the services I receive via the UpLift platform.
I understand that my provider has the right to determine that my needs are not appropriate for in person or remote treatment and as a result, I may need to seek alternative treatment methods.
I understand that mental health care may not be an exact science and that diagnosis and treatment may involve risks to my physical or mental well-being. I understand that there are risks and benefits to receiving professional therapy services. Risks of professional therapy services include the discussing unpleasant aspects of my life during therapy sessions, which may cause me to experience uncomfortable feelings.
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:
Risks of remote services include the following:
IN THE EVENT OF AN EMERGENCY, CALL 911 OR PROCEED TO THE NEAREST EMERGENCY ROOM. THIS IS NOT AN EMERGENCY SERVICE. UpLift is for non-emergency use only. Services provided via the UpLift platform are not intended to replace your primary care medical services.
I hereby acknowledge that I am aware of all potential risks associated with receiving services from UpLift, including any remote services. 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 the UpLift platform. 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 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. 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.
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 I have had an opportunity to ask questions about anything I have not understood up to this point.