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 firstname.lastname@example.org.
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.