Informed Consent for Participation in Services 

SUD Specialty Group – CA, Mental Health Specialty Group, P.A., and Mental Health Specialty Group NJ, PC, (collectively, “Group”) are Path CCM, Inc. (“Rula”) affiliated medical groups. All clinical services provided are provided by the Group and the Group’s providers (our “Providers” or your “Provider”). Rula does not provide the services described below; it performs administrative, payment, and other supportive activities for the Group and its Providers. 

This informed consent document contains important information about the Group’s and Rula’s professional and business practices. It also contains summary information on confidentiality and privacy, as well as risk and benefits of treatment services provided. Although these documents are long and sometimes complex, it is important that you understand them and ask questions. If you have questions, please reach out to your provider, or to customer service at 323-205-7088. 

SERVICES

Therapy: Psychotherapy is a confidential process designed to help you address your identified concerns, come to a greater understanding of yourself, and learn effective personal and interpersonal coping strategies. It involves a relationship between you and a licensed Provider who has the training, desire and willingness to help you accomplish your individual goals. Psychotherapy involves sharing sensitive, personal, and private information that may at times be distressing. Psychotherapy can include, but is not limited to, individual therapy, family/couples therapy, and group therapy. An important note about group therapy: As a participant in group therapy services, you are expected and required to keep the nature of the group confidential including information shared with you by other individuals in the group. 

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 as well. 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.  But, there are no guarantees about what will happen.  Psychotherapy requires a very active effort on your part. 

Medication Services: It is the Group’s and our Providers’ belief that medication might be helpful in achieving your behavioral health goals. If your Provider determines that medication might be helpful, they will tell you. It is important that medication is monitored correctly, and that you talk with a professional to ensure that the right medication and treatment plan occur. As a patient, it is important that you tell the provider about any psychological or physical symptoms, the nature of your mental health condition, how and when you take medications, side-effects, tell them about alcohol, marijuana, and other substance use, and any other information that you think is important.

When medications are prescribed as part of your treatment, your Provider will explain the risks, benefits, and alternatives of the medications. If you receive medication as part of your treatment, you agree to the following: 

• I understand that before prescribing any new controlled medications, Rula providers check the central database to review your prescribed medications.  
• I will take my medication as directed by my Provider. I understand that failure to do so may result in negative side effects or discontinuation of the prescription by my Provider. 
• I will not stop taking my medication without first speaking with my Provider. I understand that it could potentially be harmful for me to abruptly discontinue use of some medications.
• I will not sell or give away medication that I have been prescribed. I understand that, should I do so, I may be terminated as a patient and/or be reported to legal authorities.
• I will inform my Provider if I have been prescribed any new medication by another provider or specialist as soon as possible.
• I will inform my provider of any change in alcohol, marijuana, or substance use.
• I understand that a delay in my Provider receiving past records or results from testing may delay receiving my medication. It is my responsibility to ensure that these records or results are received by my Provider. 
• There is no guarantee that I will be issued a prescription and that the decision of whether a prescription is correct will be made by my Provider.  If my Provider issues a prescription, I have the right to select the pharmacy of my choice.

Additional Services: Additional services including but not limited to care coordination, care management, and patient education may be provided as part of your treatment with the Group and your Provider. 

Services are provided to treat and/or lessen the symptoms of mental health and/or substance use disorders.

CONFIDENTIALITY

Confidentiality is essential to providing effective services. For services to work best, you should feel safe about sharing personal information about yourself with your Provider. When you share information about yourself with your Provider, they will respect the importance of that information. In general, there are some limits to confidentiality including but not limited to: 

• If you are reasonably suspected to be in imminent danger of harming yourself or someone else
• If you tell a Provider about sexual misconduct, the Provider is required to report it to authorities.
• If you talk about any abuse, neglect , or maltreatment of children and adolescents, the elderly, or disabled persons the Provider is required to report it to authorities.
• In criminal proceedings, in response to a subpoena, or other legal proceedings

Policies about confidentiality, as well as other information about your privacy rights, are fully described in a separate document entitled Notice of Privacy Practices. You have been provided with a copy of that document. Please remember that you may ask questions about confidentiality at any time during your treatment. 

TELEHEALTH CONSENT

Telehealth involves the use of secure electronic communications, information technology, or other means to enable a healthcare provider and a patient at different locations to communicate and share individual patient health information for the purpose of rendering treatment. The following describes the risks, benefits, and limitations of using telehealth platforms to receive services. 

The Group uses Zoom to allow Providers to provide services via telehealth. Zoom has high standards to provide a secure and encrypted platform and does not record any communications between you and your Provider whether audio or video. Zoom has security protocols to protect the confidentiality of patient identification and imaging data and includes measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.  All the Services delivered to you through telehealth will be delivered over a secure connection that complies with the requirements of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). In addition, the Provider will deliver your care in a confidential setting from their place of business. 

At times there might be another person present during the telehealth visits other than your Provider in order to assist in the operations of the telehealth technology. If another person is present during the telehealth visit, the Provider will inform you of the individual’s presence and role. 

Services may be provided in a variety of formats including:  synchronous (real-time audio and video) 2) asynchronous or store and forward (information is shared at a later time) 3) remote patient monitoring (data collected and given to the provider)  

Benefits 

The use of telehealth has certain benefits, including:

• Comfort and convenient care
• Easier access to care and follow-up as services allow you to remain in your preferred location
• More efficient care evaluation and management. 
• Ability to more efficiently obtain expertise of a specialist as needed.
• Ability to allow family members and others you want involved in your care to participate in your care.

Risks and Limitations: 

Although using electronic means for appointments is increasingly common, there are potential risks to using an online telehealth platform:

• Internet services may malfunction or there may be technological challenges.  Therefore, a back-up option may need to be used, which can result in potential misunderstandings due to a lack of visual cues. 
• Though every effort is made to ensure confidentiality, the limitations and risks in teleconferencing include public discovery, possibility of hackers, household noise or interruptions and other potential risks outside of our control.
• There is a risk of technical failures during the telehealth visit beyond the control of Group.  
• It may not be possible to do every type of visit remotely. You may still have to go into a clinic or laboratory for things like imaging tests and blood work. 
• Even with best practices using telehealth, any information transmitted via the internet may not be 100% secure.
• Delays in treatment could occur due to deficiencies or failures of the equipment and technologies, or Provider availability. In rare events, your Provider may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled appointment or an in-person meeting with your Provider or your local primary care doctor.

ELECTRONIC COMMUNICATIONS

Electronic communication can include email, text messages, and phone/voicemail. Communicating electronically with the Group and your Provider has benefits, including but not limited to more prompt access to your Provider and reminders of upcoming appointments. However, communicating electronically also has its risks, including but not limited to the below: 

• Standard email services, including, but not limited to, Yahoo, Hotmail, and Gmail, are not secure. Text messages are also not secure. This means that the emails and texts, that include any individually identifiable health information and other sensitive or confidential information are not encrypted and could be misdirected, disclosed to, read or intercepted by, anyone.

You have the right to choose how you communicate with your Provider. Electronic communication should not be used for emergencies. In an emergency situation, please call 911. Electronic communication will be used by the Group and/or its Providers for scheduling appointments and sending appointment reminders. You must notify your provider if you do not wish to receive any communications electronically, such as email, text messages, and/or phone/voicemail. If you choose to communicate via email, text messages, and/or phone/voicemail with the Group and Providers you agree to release and hold harmless the Group, its provider(s) and their staff, employees, affiliates, agents, officers, and principals from any and all expenses, claims, actions, liabilities, attorney fees, damages, losses of any kind that may have or could result from electronic communications between the Group, its providers, and me and/or the minor identified based on this authorization given to the Group and my Provider to communicate with me via electronic communications.

ACCESS TO SERVICES AND EMERGENCIES

If you need follow-up care, assistance in the event of an adverse reaction to treatment, or in the event of an inability to communicate as a result of a technological or equipment failure, please contact 323.205.7088 or support@rula.com 

Please coordinate a plan with your provider for crisis and psychiatric emergency services.  If you believe you are experiencing a behavioral health emergency or a medical emergency, call 9-1-1 and/or go to the nearest emergency room. You may also call the toll-free National Suicide Prevention Lifeline at (800) 273-8255. It will be important to discuss any emergency treatment you receive with your Provider at your next scheduled visit.  

By signing this form I further acknowledge that:

I understand that prior to my first telehealth visit, I will be given an opportunity to select a Provider as appropriate, including a review of the Provider’s credentials, or I have elected to visit with the next available Provider from the Group, and have been given my Provider’s credentials.

I may elect to seek services from a medical group with in-person clinics as an alternative to receiving telehealth services.

I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time without affecting my right to future care or treatment.

Dissemination of any patient-identifiable images or information from the telehealth visit to researchers or other educational entities will not occur without my consent unless authorized by state or federal law.

I understand that by creating a treatment plan for me, my Provider has reviewed my medical history and clinical information and, in my Provider’s professional assessment, has made the determination that the provider is able to meet the same standard of care as if the health care services were provided in-person when using the selected telehealth technologies.

I understand that there is no guarantee that I will be treated by a Group Provider. My Provider reserves the right to deny care for potential misuse of the Services or for any other reason if, in the professional judgment of my Provider, the provision of the Services is not medically necessary, safe, or ethically appropriate.

I understand that I have the right to withdraw my consent in the course of my care at any time without affecting my right to future care or treatment. I will notify my provider if I want to withdraw my consent and understand that I may be referred elsewhere for treatment. 

I understand that electronic communication should never be used for emergency communications or urgent requests. Emergency communications should be made to the existing crisis/emergency and 911 services in my community.

I understand my patient rights and that I can access a copy of my patient rights on the Rula website.

I certify that I have read, understand and agree to abide by the information, terms and conditions contained in this Informed Consent. I have had the opportunity to discuss any questions about the information contained in this form. I hereby give my consent to receive services.