Informed Consent to Telehealth Services

Effective Date: April 1st, 2020

I. General Information

Mindstrong through its affiliated health care practices and providers (“Mindstrong”, “we”, “us”, or “our”) provides healthcare services delivered through the Mindstrong App using asynchronous and/or synchronous telehealth technologies. Health care providers that provide services via the Mindstrong App may include primary care and behavioral health physicians, psychologists, social workers, clinical counselors, and other caregivers (the “Providers”). If your group health plan, insurer or other organization has elected to make telehealth services available to you through Mindstrong, by agreeing to the terms and conditions of this informed consent (this “Informed Consent”), you consent to receive the telehealth services delivered to you through Mindstrong by Providers located at sites remote from you.

In exchange for your use of the Mindstrong App to receive medical treatment, you acknowledge and agree to the following terms and conditions of this Informed Consent:

II. Overview of Mindstrong Services

You understand that licensed and qualified Providers and other Mindstrong care team personnel provide the telehealth services through the Mindstrong App, tailored to your needs. The telehealth services include, but are not limited to:

III. Information About Telehealth

The health care services through the Mindstrong App are a type of “telemedicine” or “telehealth” service. The information that you provide to Providers may be used for diagnosis, treatment, follow-up and/or education. Telehealth services may include live two-way texting, audio, and video and other materials (e.g., your medical records). The scope of the telehealth services delivered to you through the Mindstrong App will be at the sole discretion of your Providers, with no guarantee of diagnosis, treatment, or prescription. The Provider will determine whether or not the condition being diagnosed and/or treated is appropriate for a telemedicine or telehealth encounter via the Mindstrong App.

If receiving telehealth services, you agree to disclose your location at the beginning of every session, to keep your emergency contact up to date, and to make a reasonable effort to be in a quiet, private location for any sessions conducted by phone or video. You agree that neither you nor Mindstrong will record any interaction without informing the other person(s). You have the right to be informed of any party who will be present during the telehealth consultation, and may, at any time, exclude anyone from being present and/or object to the recording of the telehealth consultation.

As with any medical or other healthcare professional procedure or service, there are potential risks associated with the use of telemedicine or telehealth services, which may include, without limitation, the following:

You acknowledge that, although Mindstrong strives to prevent unauthorized access to information about you through encryption of information transmitted by the Mindstrong App and other security measures, Mindstrong cannot guarantee that your use of the Mindstrong App and the information will be private or secure, and you consent to this risk.

Benefits of telemedicine or telehealth services may include:

The alternatives to telehealth services is in-person care. You have the right to request in-person care, in which case your Mindstrong care team can help you connect to an in-person health care provider outside of Mindstrong. Upon our request, we can coordinate with your in-person health care provider while you continue to receive telehealth services from your Mindstrong Providers.

IV. Risks and Benefits of Psychotherapy

As part of your Mindstrong services you may have access to telehealth psychotherapy. Psychotherapy has both benefits and risks. Risks may include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of psychotherapy often requires discussing the unpleasant aspects of your life. However, psychotherapy has been shown to have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. Psychotherapy requires an active effort on your part. In order to be most successful, you will have to work on things outside of sessions. You understand that telehealth therapy services may not be as complete as face-to-face services, and Mindstrong makes no guarantees or assurances as to results.

V. Confidentiality

By participating in telehealth services with Mindstrong your medical information will be kept confidential. You understand and agree that Mindstrong or a Mindstrong Provider may share your medical information in the circumstances outlined below, in accordance with our HIPAA Notice of Privacy Practices, or unless otherwise prohibited by HIPAA. You understand that Mindstrong Providers may be required by law to share your information in the following circumstances, and any other circumstances required by law:

You further agree that Mindstrong Providers may share your health information in the following circumstances, and any other circumstances permitted by law:

In addition, you agree that Mindstrong may share your healthcare data with your healthcare insurance plan for the purpose of demonstrating quality care and effective outcomes.

VI. Cost and Other Fees

Mindstrong telehealth services are generally provided at no additional cost to your health plan coverage. However, you understand that there may be additional services not covered by your health plan (e.g., lab tests), and you may have and are responsible for any out-of-pocket costs. You should contact your Provider or health plan to discuss coverage of Mindstrong telehealth services.

VII. Termination from Mindstrong Services

You or your Mindstrong Provider may end specific telehealth services without ending your membership with Mindstrong. For example, therapy or psychiatric services will be terminated when it becomes reasonably clear that services are no longer needed, are no longer benefiting you, or if there is recognized harm by ongoing services. The termination process will be clearly defined and communicated to all parties involved.

If you are no longer eligible for Mindstrong services because you change healthcare insurance providers, move to a state where Mindstrong does not provide services, or are no longer eligible based on the criteria of the program you enrolled with, your Mindstrong care team will work with you for up to three months to help you transition to new health care providers. Mindstrong reserves the right to terminate telehealth services if you display vulgar, disrespectful, or threatening behavior toward Mindstrong Providers, administrative staff, or other support staff.

You have the right to withdraw consent at any time without affecting your right to future care or treatment through other entities. If you withdraw consent, you are no longer eligible for Mindstrong services and are required to immediately inform Mindstrong through the App, and your services would be immediately terminated.

VIII. Informed Consent Statement

By accepting this Informed Consent, you acknowledge and accept the risks identified above and the terms associated with the receipt of telehealth services with Mindstrong and give your consent to receive telehealth services under the terms described herein.