Informed Consent for Services & Patient Responsibility Policy Parent or Guardian of Minor

By typing your name and clicking “I agree to the Terms of Service” on the Spring Health website, you agree on behalf of the minor patient:

1. I understand that the laws that protect the privacy and the confidentiality of medical information also apply to telemedicine and that no information obtained in the use of telemedicine which identifies me will be disclosed to other non-covered entities without my consent.
2. I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.
3. Subject to applicable law, I understand that I have the right to inspect medical information obtained and recorded in the course of a provider visit, and may receive copies of this information for a reasonable fee.
4. I understand that a variety of alternative methods of medical care may be available to me and that I may choose one or more of these at any time.
5. I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.
6. I understand that I may need to provide photo-identification and my physical location to allow for accurate and effective care to be delivered.
7. I understand that if I am having a medical emergency that I should immediately contact my personal physician, local emergency notification system, or go to the nearest emergency room.
8. I understand that it is my duty to inform my provider of interactions regarding my care that I may have with other healthcare providers.
9. I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.
10. I have read and understand the information provided below, have discussed it with my provider or such assistants as may be designated, and all of my questions have been answered to my satisfaction.
11. I hereby give my informed consent for the care outlined below and, if applicable, the use of telemedicine in my medical care.
12. I have read and understand the General Terms and Conditions below and agree to the policies outlined in this document.

General Terms and Conditions

Our services may include, without limitation, psychotherapy and medication management and may be performed using telehealth as a treatment modality. For some people, in-person psychotherapy and medication management may be available. Providers may include primary care practitioners, masters-level and doctoral-level therapists, psychiatrists or other specialists.

Psychotherapy

Often called talk therapy, this form of treatment can be helpful to individuals. Benefits can include improved mood, improved relationships, and resolution of specific problems. However, therapy is not guaranteed to work for everybody. Psychotherapy may also require exploring unpleasant aspects of your life and can, at times, lead to feelings of distress (i.e., guilt, anxiety, frustration, etc.) or a temporary increase in symptoms. These unpleasant aspects are generally temporary but are important to discuss when present. Thus, it is important to let your therapist know if you feel that your goals aren’t being met. These issues can be addressed in sessions, which typically last 50 minutes. Occasionally, therapists need to discontinue therapy. Although this is rare, if therapy ends prematurely, a suitable referral or transition will be discussed with you.

Medication Management

Medications may be indicated when your symptoms are not responsive to psychotherapy alone. When a mental illness markedly impacts your ability to work, maintain interpersonal relationships, or properly care for your basic needs, medication may offer much-needed relief. Not everyone is a good candidate for medication treatment. Such treatment requires adherence to prescribed dosing frequency and close follow-up. Your ability to adhere to medication treatment will be taken into consideration in making the decision to start such treatment. Additionally, your physician will discuss the risks, benefits, side effects, government warnings, and alternative treatments (which always includes not using medications) with you to help you determine the best treatment options available for your specific needs. Current federal law does not allow tele-providers to prescribe controlled substances without an in-person visit. If your tele-provider determines you need this type of medication, you may be referred to your primary care provider with a recommendation to prescribe this medication

Limitations to Evaluation Types

Spring providers are not able to provide the following types of evaluations: a return to work fitness for duty evaluations, parental custody evaluations, court-mandated treatment, emotional support animal evaluations, weapons purchase clearance evaluations or other similar administrative evaluations. Patients may request a copy of their patient record or ask for a statement letter for attendance at sessions. This information will be sent directly to patients. Patients can share these records directly with any agency of their choice. Spring and associated providers will not send patient records directly to any third party that is not involved in your patient care.

Consent to In-Person Care

If in-person psychotherapy or medication management services are available to you, and you chose to engage in those services, you certify that a provider has explained the nature, benefits, and potential risks of those services, and that you have been given the opportunity to ask questions about any concerns regarding the services.

Telehealth as a Treatment Modality

Telehealth involves the use of audio, video and other electronic communications to enable health care providers to access individual patient medical information for the purpose of patient care. As part of this process, your provider may need to verify your identity as well as ask your location during a session to provide effective care. Details of your medical history and personal health information may be discussed with you or other health care professionals through the use of interactive video, audio, or other telecommunications technology. Some patients do not find distance counseling to be as intimate or helpful as traditional in-person counseling. Often times, this is because it is a new way of communicating. However, once patients have participated in a couple of sessions they find that they can benefit from using telehealth. If you decide telehealth is not for you, you should promptly notify your therapist or Spring Care Navigator so an alternative, more effective mode of treatment may be arranged (by Spring and/or a third-party provider).

Expected Benefits of Telehealth:

• Improved access to medical care by enabling a patient to obtain consultations from a wider range of healthcare practitioners at distant/other sites that are not available for in-person care
• More efficient medical evaluation and management with a wider range of appointment availability compared to only in-person care
• More convenient care scheduling and logistics

Possible Risks of Telehealth:

As with any medical evaluation and treatment, there are potential risks associated with the use of telehealth. These risks include, but may not be limited to:

• In rare cases, information transmitted may not be sufficient (e.g. poor connectivity) to allow for appropriate medical decision making by care providers;
• Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment;
• In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information;
• In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors;
• In some cases, it may be difficult for providers to track your location and guide your care in emergency situations;
• In some cases, you may have multiple individuals involved with your care to determine the ideal plan of treatment; these individuals may be psychotherapists, physicians, medical administrators, and care navigator staff.

Electronic Information/Systems:

Electronic information collected during your sessions may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:

• Patient medical records and electronic/paper communications
• Live two-way audio and video
• Output data from sound and video files
• Messaging appointment reminders to your phone

Electronic systems used in your care will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

Personal Health Information Data Management:

Spring follows all applicable HIPAA federal guidelines in protecting and managing your data. Under HIPAA, you have a right to get a copy of your medical record, correct your medical record, ask us to limit the information we share, receive a list of those with whom we have shared your information, get a copy of this privacy notice, choose some to act for you and file a complaint if you believe your privacy rights have been violated

Under HIPAA, Spring is allowed to share your data without your consent with business associates with an HIPAA agreement in place for the following reasons: to facilitate your treatment; run our organization; bill for your services; help with public health and safety issues; do research; comply with other laws; address workers compensation, law enforcement, and other government requests; and respond to lawsuits and legal actions.

For more information on management of your protected health information contact your care navigator.

Patient Responsibility/Missed Appointment Policy:

• Spring is not an enrolled Medicaid or Medicare provider. If Spring does not participate in your health care plan, you may be responsible for greater out-of-pocket expenses than you would for an in-network service. You may submit a request for an estimate of the amount that you will be billed for the out-of-network service. Please submit your request to https://www.springhealth.com/support

• All out-of-network costs (OON) and self-pay members are required to pay the full session price on the day of session. Invoices will be delivered via email. At the end of each month, you will receive a superbill to reflect all services rendered and payments made. You can then independently submit the superbill to your insurance or coinsurance carrier for any possible reimbursements under your insurance plan.
• If Spring participates in your health care plan, you will be required to pay the in-network deductible or co-pay, according to your plan, within 24 hrs of the service rendered. Invoices will be delivered via email.
• If your employer offers a number of no cost visits per calendar year, you will be responsible for payment for any additional visits beyond those no cost offerings. Your insurance may cover a portion of those costs, as noted in the in-network and out-of-network notes above.
• Any outstanding balance is subject to a finance charge of 3% after 60 days past due.
• I understand all appointments have to be confirmed by me in advance to retain my time slot.
• If I cancel a visit within 24 hours of a scheduled telehealth visit, then I am responsible for a cancellation processing fee of $50 (or I will have an employer-sponsored visit deducted).
• If I am over 10 mins late to a telehealth therapy visit, it is up to the provider’s discretion to cancel or shorten a visit. If canceled, then I may be responsible for a cancellation fee as above.

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