Terms of Service and New Patient Agreement, Consent to Treatment, Privacy Policy, and Telehealth Consent

Last updated: August 30 2024

NEW PATIENT AGREEMENT

Summary

This summary is not a full and complete recitation of the New Patient Agreement (“Agreement”).  It is an attempt to capture in broad terms the nature and scope of the Agreement.  This summary has been prepared in an effort to highlight key elements of the Agreement in an abbreviated format, not to replace it.  By confirming the Agreement below, you certify that you have read the full Agreement and that you agree to and understand its terms. 

• You hereby certify that you are (i) over the age of eighteen (18) or have the legal ability to consent to Medical and/or Counseling Services (as defined below), or (ii) you are the parent or legal guardian of the patient and have the legal authority to consent to Medical and/or Counseling Services on behalf of the patient.
• You are a resident of the state of California.
• Confidentiality of your patient information and privacy is critically important and we encourage you to communicate with us through the patient portal, software by IntakeQ (labeled as Remedy), to protect your patient information.
• Patients and/or parents or legal guardians of the patient agree to pay the following fees as listed below (including missed appointment fees) and any fees incurred through medical insurance bills or pharmacy costs.
• If patients require completion of medical paperwork (included but not limited to: state or personal disability forms, emotional support animal letters or forms), patients agree to, and are billed at $2.50 per minute for completion of these services if not covered by insurance.
• Remedy Psychiatry is not intended for the provision of a clinical diagnosis requiring an in-person evaluation, and you should not use it if you need any official or legal documentation or approvals for purposes such as, but not limited to, court-ordered evaluations. 
• Remedy Psychiatry is not for patients with pain, opiate or substance addiction treatment, clozapine treatment, those needing benzodiazepines prescribed every day, or for patients seeking emergent treatment.  If such services are required, patients should seek alternate treatment. 
• Medical team will respond to patient requests within 48 business hours; for life-threatening emergencies, patients should always immediately dial 911 or go to the nearest emergency room.
• You consent to our use of your name, phone number, and email address for the purpose of communicating with you about our services, billing, appointments, and related business interactions between you and us.

The full text of the New Patient Agreement follows: 

Agreement

This  Agreement, effective as of the date of the Member’s digital confirmation of receipt (the “Effective Date”), is made by and between Remedy Psychiatry, Inc. a California professional corporation (“Remedy” or the “Practice”), on behalf of itself, its employed or contracted physicians, nurses, nurse practitioners, counselors and other support personnel (“Providers”), and its  contractual affiliates (“Affiliates”) and/or other non-contractual associates (“Associates”), and the undersigned patient member (the “Member” or “You”).

Services Provided

The Practice will provide or arrange for the provision of certain virtual health care services (“Medical Services”) and related administrative, payment and non-medical support services (“Concierge Services”) (collectively, the “Services”). The Medical Services are further described in Appendix 1. The Medical Services will be provided by Providers who are qualified and appropriately licensed in the state where You are located and may consist of consultation, diagnosis, treatment recommendation, prescription, and/or a referral to in-person care outside of the Practice, as determined clinically appropriate by your Provider. The Concierge Services are further described in Appendix 6, which may be adjusted as necessary from time to time. The Concierge Services may involve the Practice’s Affiliates and Associates, and are intended to supplement the Medical Services that You receive from the Practice, but the Concierge Services shall not include Medical Services.

The purpose of this Agreement is to set forth the terms and conditions under which the Medical and Concierge Services will be furnished to You by the Practice. You and the Practice therefore agree as follows:

 

Definitions

• “Member” – a person for whom the Practice shall provide Services, and who is a party to this Agreement.
• “Insurer” – private health insurance policy, an individual or group health plan, HMO, PPO, or other similar private health plan or coverage.

Treatment of Minors Under the Age of 18

The Practice offers Services to minors in accordance with California law and Practice policy, which may be amended from time to time. In some cases, the Practice must have the consent of the minor patient’s parent(s) or guardian(s) to provide mental health treatment, barring circumstances in which obtaining a parent’s or guardian’s consent may cause significant harm, in which case the Practice reserves the right to refer to alternative, specialized agencies. In cases where only one parent/guardian has custody or power for medical decision-making, the Practice may need documentation substantiating such. It is the policy of the Practice that, unless a minor lawfully consents to treatment without parent/guardian involvement, a parent or guardian must be present for all or part of the initial evaluation, and must maintain ongoing involvement in treatment as deemed appropriate by the treating Provider, with the caveat that a minor may express their preferences for what they want their Provider to share. This will not always direct treatment, but it is at the discretion of the Provider to keep information confidential with their minor patients to ensure the creation of a safe space for the younger individual and improve their treatment outcomes. However, if there is an immediate safety concern, the parent(s)/guardian(s) will be promptly notified.

If there is more than one parent or guardian to a minor patient, both parents/ guardians must be present or available during the initial evaluation and any subsequent appointments in which their presence is requested by the treating Provider. If both parents/guardians cannot be available for a particular appointment, then the Provider may permit the parents/guardians to designate one parent/guardian to be present during the appointment who will be responsible for providing any necessary  consents, communicating on their behalf with the Practice, and relaying any relevant treatment information to the other parent/guardian. If one parent/guardian requests a second appointment to discuss what was already discussed during an appointment in which the other parent/guardian was present, this will be billed as a second appointment if using insurance, and if using the Remedy membership model, may be subject to a second Remedy membership and associated fees. If parents/guardians have a relationship such that both being present for appointments on a regular basis is impossible, or disagreement is such that a treatment plan cannot be agreed upon between the Practice and both parents/guardians, the minor patient and family may be referred to another treatment setting for a higher level of care.

 

Payment for Patients without insurance, or with out-of-network insurance

To become and remain a Member, after your initial on-boarding appointment, You agree to pay the Practice a monthly fee, which may be adjusted for subsequent membership years. Members will be notified of any pricing changes in advance of implementation. The fee for your initial membership year is subject to individual adjustments, payment plans, and discounts.

Adult patients age 18 and over will be charged a non-refundable $189 monthly fee for the first month of your subscription and $99 per month thereafter. Parents and/or legal guardians of patients under the age of 18 will be charged a non-refundable initial fee of $209 for the first month, and a monthly subscription fee of $109 per month starting in their second month. 

In some cases, discounts and alternative pricing may be made available (for example, yearly pricing or a free trial period). This monthly fee is incurred whether or not You have an appointment or communicate with your Provider during that month.

If You cancel your initial on-boarding appointment with your Provider within 24 business hours of your appointment time, You will be charged a $99 missed appointment fee if You are age 18 or over and $99missed appointment fee for patients under the age of 18. If You do not attend your initial Appointment (commonly referred to as a “no show”), You will be charged a $99 missed appointment fee if You are age 18 or over and $99 missed appointment fee for patients under the age of 18. If You cancel your follow-up appointment with your doctor within 24 business hours of your appointment time, You will be charged a $99 missed appointment fee if You are age 18 or over and $99 missed appointment fee for patients under the age of 18. If You do not attend your follow-up appointment (commonly referred to as a “no show”), You will be charged a $99 missed appointment fee if You are age 18 or over and $99 missed appointment fee for patients under the age of 18. Any missed appointment fees, or no-show fees must be paid before You will be rescheduled. 

Patients must keep an active credit card on file for all Services. If this credit card is expired, or no longer works, patients will be contacted for updated credit card information. If the Practice is unable to obtain appropriate payment information or You decline to work with the Practice to establish a new payment plan, the Practice may view this as an expression of intent to terminate your treatment relationship with the Practice and/or your Provider. In accordance with Practice policy, which may be amended from time to time, You will be provided advance notice of any termination decision through the Practice’s patient portal so You can seek care elsewhere. In some cases, an HSA or FSA card may be used for payment for Remedy psychiatry services. Each plan is different and You must contact your HSA/FSA plan to determine if You can use your card for Remedy care. 

Recurring Billing Policy 

Our subscription model is a monthly recurring charge and the billing period begins from the time of registration, as defined by when You enter your payment method. By agreeing to our recurring billing terms, You are agreeing to the following:

You represent and warrant that (i) any credit/debit card information You supply is true, correct and complete, (ii) charges incurred by You will be honored by Your credit/debit card company, (iii) you will pay the charges incurred in the amounts posted, including any applicable taxes, and (iv) You are the person in whose name the credit / debit card was issued and You is authorized to make a purchase or other transaction with the relevant credit / debit card and information.

You agree and authorize the payment method to be billed automatically for the entire subscription length, according to the published pricing on the Remedy Psychiatry, Inc. website, which is subject to change at any time.

You agree and authorize the payment method to be billed beginning on the date of registration and subsequently on a monthly basis regardless of whether the assessment has been completed or Services have been rendered (including, but not limited to, provider visits, and medication prescription and delivery).

If Remedy Psychiatry, Inc. is unable to secure funds from your debit / credit card(s) for any reason, including, but not limited to, insufficient funds in the debit / credit card or insufficient or inaccurate information provided by You when submitting electronic payment, Remedy Psychiatry, Inc. may undertake further collection action, including application of fees to the extent permitted by law.

You have the right to revoke this authorization by contacting Remedy Psychiatry, Inc. via email or the patient messaging portal by 9:00AM PT one business day prior to the scheduled payment date. You understand and acknowledge that Services may be canceled or withheld if You revoke this authorization, and that You are still responsible for all charges incurred by You or otherwise owed to Remedy Psychiatry, Inc. This authorization will remain in full force and effect until revoked by You or Remedy Psychiatry, Inc.

You acknowledge and agree You will not dispute the payment with the credit / debit card company, provided the transactions correspond to the terms indicated in this authorization form. No refunds.

Subscriptions 

If You purchase a subscription to the Services (“Subscription”), with the exception of any free trial periods, the Practice will charge You a Subscription fee at the rate presented to You (“Subscription Fee”). The Subscription gives You access to the Services for one month, or a different subscription period selected on the Platform (“Subscription Period”). Unless otherwise stated when You sign up for a Subscription, your selected Services will automatically renew for a further Subscription Period with the Subscription Fee (including any applicable taxes) and will continue to do so unless the Practice is either no longer offering that Service, in which case it shall notify You, or your Subscription has been canceled in accordance with this Agreement. 

The billing period for your Subscription Fee begins from the time of registration (i.e., when You register, enter your payment method and pay the initial Subscription Fee), and again at the start of each subsequent Subscription Period. By signing up for a Subscription, You agree to pay your Subscription Fee in full each Subscription Period and authorize your payment method on file to be billed automatically each Subscription Period by the Practice’s third-party payment processor for the entire length of your Subscription, regardless of whether or not You have used the Services during the Subscription Period, until your Subscription ends or is canceled. If any Subscription Fee is not paid in a timely manner, or your transaction cannot be processed, we reserve the right to suspend, disable, cancel or terminate your Subscription. You will be responsible for paying all past due amounts. You acknowledge that billing may not occur on the exact same date of each month.

Insurance

If You have health insurance, your insurance plan may cover all or a portion of your use of the Services prescribed medication filled by pharmacies, and/or laboratory products and services provided by laboratories. Subject to the terms of any written agreement between the Practice, its billing partners (such as Alma, Headway, Trizetto or another billing company), and the insurance plan, if You provide any information about your health insurance to us, that will be deemed your authorization for the Practice, its billing partners, the pharmacies and laboratories, and/or one of their Associates, Affiliates, or Providers to submit claims and bill for services on your behalf and share necessary information with the insurance plan to process payments and reimbursements. The Practice is not enrolled with state health care programs such as Medicaid, Medicare or Medi-Cal. The Practice’s receipts or superbills are not eligible for submission to Medicaid, Medicare or Medi-Cal.

If the Practice is in-network with your insurance plan, You may be responsible for payment for co-pays for visits with Providers, co-pays for prescribed medication (including refills), certain laboratory tests ordered by a Provider, or co-insurance or deductibles, which will vary depending on your insurance plan and may be billed separately. Billing is currently done through billing partner, Alma, Headway, Trizetto or another billing company. You are also responsible for any Other Fees incurred that are not paid by insurance (e.g., appointment no-show fees, fees to complete paperwork, etc.). Any co-pays, co-insurance, deductibles or Other Fees (as defined below) are your responsibility, not that of your insurance plan, even if the Practice is considered in-network. 

Your insurance policy is a contract between You and your insurance plan, and it is your responsibility to know your benefits, including if your insurance has any deductible, co-payment, co-insurance, out-of-network, usual and customary limit, prior authorization requirements or any other type of benefit limitation for the Services You receive, and how your benefits will apply to your payments. If You purchase Services with your insurance plan, You authorize the Practice or one of its Associates, Affiliates, Providers, or third party partners, including billing partners (such as Alma, Headway, Trizetto or another billing company), pharmacies or laboratories to charge your payment method on file for any fees not covered by your insurance, such as co-pays, co-insurance, deductibles, and Other Fees, including no-show fees or fees to complete paperwork. If all or any portion of the Services are not covered or paid by your insurance plan for any reason or You do not have health insurance, You understand that You will be ultimately responsible for all fees and costs arising out of your use of the Services and agree to pay the full amount of all Practice fees. Questions about non-payment should be directed to your insurance plan. You agree to inform the Practice or your Provider immediately if You lose your health insurance and/or can no longer pay for treatment.

You understand that while your insurance may confirm your benefits, confirmation of benefits is not a guarantee of payment and that You are responsible for any unpaid balance.

You understand and agree that it is your responsibility to know if your insurance has any deductible, co- payment, co-insurance, out-of-network, usual and customary limit, prior authorization requirements or any other type of benefit limitation for the services You receive and You agree to make payment in full.

You understand that a third-party company (such as Alma, Headway, Trizetto or another billing company, or another billing company) will be used to bill your insurance for the Services, and that this will entail providing your information (including name, date of birth, address, phone number, insurance information) to that third party company for the purposes of using your insurance to pay for the Services. 

You understand that even for insurers for which the Practice is in network with, you have the option of not using your health insurance. If you elect to not use your health insurance, you are aware that your Provider, the Practice, and any of the Practice’s billing partners, will not bill any third party or insurance companies for any services or fees incurred while you receive services. As a result, you understand that the fees you pay will not count towards any deductible you may have. Additionally, you will not be eligible to submit a superbill for reimbursement of these fees if the Practice is considered an in-network provider. You understand that if you decide to use your insurance coverage for future services, you will notify the Practice in writing, and that any services provided before written notice is given to the Practice will not be billed to your insurance.

The Practice and/or any billing partners (including Alma, Headway, Trizetto or another billing company), will electronically verify your health insurance benefits in advance of your appointment and will inform You of the expected co-pay amount for each visit. However, insurance companies may clearly state that verification of benefits does not guarantee payment. If your insurance company fails to pay Subscription Fees or Other Fees, You will be responsible for the cost of the visit. A complete list of fees is available from the Practice’s request. Payment is expected at the time of service. The Practice gladly accepts most major credit cards. A receipt and/or insurance statement will be provided at the time of billing. 

 

Changes to Subscription Fees, Other Fees or Subscription Features

All fees published by the Practice are set by the Practice in its sole discretion and it may change our fees from time to time. The Practice will send notice of upcoming automatic renewal prior to renewing your Subscription as required by law. The Practice may change the Subscription terms, Subscription Fees or Other Fees at any time on a going forward basis at our discretion. If the pricing for your Subscription increases, the Practice will notify You, and provide You an opportunity to change or cancel your Subscription before applying those changes to your account or charging You in connection with an automatic renewal. The Practice may choose in its sole discretion to add, modify, or remove benefits and features from a Subscription. Your continued enrollment in your Subscription after the changes become effective will constitute your acceptance of the changes. If You do not wish to continue your Subscription at the revised rates and/or terms, You must inform the Practice, in writing, prior to the end of your then current Subscription Period, otherwise the revised rate and/or terms will apply on and from the next Subscription Period.

If You aren’t sure about your benefits, please contact your insurance provider. We can also see You as an out-of-network provider and provide You with a “superbill” to submit to your Insurer for possible reimbursement. Please also contact your insurance company for details on your level of possible reimbursement for out-of-network visits.

Third-Party Payment Processor

All credit card, debit card, and other monetary transactions on or through the Platform occur through an online payment processing application that is provided by a third-party payment processor(s). The Practice itself does not collect or store payment card information. If our third-party payment processor is unable to secure funds from your payment method for fees that are due for any reason, including, but not limited to, insufficient funds or insufficient or inaccurate information provided when submitting electronic payment, the Practice may undertake further collection action, including application of fees to the extent permitted by law, and reserves the right to suspend or terminate your account or Services in accordance with Practice policy, which may amended from time to time.

Other Fees

You agree to pay all other fees and charges associated with the Services and your Remedy Psychiatry account that are not included in the Subscription Fee, including, for example, appointment no-show fees, cost of prescribed medication and refills, costs of laboratory tests, co-pays, co-insurance and deductibles and other costs not covered by your health insurance plan, and any fees for any Services that are not charged on a Subscription model (collectively, “Other Fees”), on a timely basis and according to the terms and the rates presented to You. By using the Services and incurring such Other Fees, You authorize us to bill and charge your payment method on file for such Other Fees in full. 

Maintaining Patient Status

Patients who are doing reasonably well, with mild symptoms, or with conditions in remission, must be seen at least once every three months to maintain active status. If a patient is unwilling to be seen at least once every three months, their file may be closed and they may be discharged from the Practice.

Good Faith Estimate

This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created. The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. 

You are welcome to request an oral explanation of this Good Faith Estimate by calling us at 747-212-3876. Additionally, the specific list of services, diagnosis code, TIN and NPI numbers can be provided to You upon request. You may contact us to let us know if the billed charges are higher than the Good Faith Estimate. To learn more, go to www.cms.gov/nosurprises.

You have the right to receive a Good Faith Estimate explaining how much your medical care will cost.

Under the law, health care providers need to give patients who do not have insurance or who are not using insurance an estimate of the bill for medical items and services (the “Good Faith Estimate”).

You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs, like medical tests, prescription drugs, equipment, and hospital fees. Make sure your health care provider gives You a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can ask your health care provider, and any other provider You choose, for a Good Faith Estimate before You schedule an item or service.

• If You receive a bill that is at least $400 more than your Good Faith Estimate, You can dispute the bill.
• Make sure to save a copy of your Good Faith Estimate.
• For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 800-985-3059.

For adults, age 18 and over, the fees for service(s) with Remedy Psychiatry, Inc. are billed each month, starting the month You initiate care and sign this terms of service, with the initial month of care $189, then $99 per month thereafter, and continued until You submit a request in writing to terminate your membership and care. This monthly fee is incurred even if You did not have an appointment or require use of services during any given month. The estimated cost of care for an adult age 18 and over for the first 12 months is $1388 total [which is ($189 x 1 month for first month of care) + ($99 per month x 11 months remaining in the year)]. If You elect to continue care with Remedy beyond your first year, your annual estimated cost for years two and beyond is $1308 per year [which is ($99 x 12 months)], and You will be notified in advance if this monthly fee is to increase. Additionally, if You do not show up for an appointment or are late for an appointment, You will be charged an additional $99 for each missed appointment, in addition to the above care estimate. The total fees incurred include the above estimated cost of annual care, plus $99 multiplied by the number of appointments You miss per year.

For children, age 17 and younger, the fees for service(s) with Remedy Psychiatry, Inc. are billed each month, starting the month You initiate care and sign this terms of service, with the initial month of care $209, then $109 per month thereafter, and continued until You submit a request in writing to terminate your membership and care. This monthly fee is incurred even if You did not have an appointment or require use of services during any given month. The estimated cost of care for a child under age 18 for the first 12 months is $1408 total [which is ($209 x 1 month for first month of care) + ($109 per month x 11 months remaining in the year)]. If You elect to continue care with Remedy beyond your first year, your annual estimated cost for years two and beyond is $1308 per year [which is ($109 x 12 months)], and You will be notified in advance if this monthly fee is to increase. Additionally, if You do not show up for an appointment or are late for an appointment, You will be charged an additional $99 for each missed appointment, in addition to the above care estimate. The total fees incurred include the above estimated cost of annual care, plus $99 multiplied by the number of appointments You miss per year.

If You require legal medical documentation, the fees for documentation are in addition to the above Good Faith Estimate, and can be reviewed in this document.

If desired, You are welcome to request an invoice that You can submit to your Insurer  for possible subscription reimbursement. This invoice, or “superbill” will include the services rendered and relevant service (CPT) code and total fees paid. Clients will need to attend at least one appointment within the billing cycle for their Insurer to review the claim. 

Telehealth Informed Consent

See Appendix 1.

Telephone and Electronic Communications

You consent to our use of your name, phone number, and email address for the purpose of communicating with You about our services, billing, appointments, and related business interactions between You and us. The Remedy patient portal is the means by which your Protected Health Information will be communicated to You. We encourage You to communicate through this portal. Communication via email may not be encrypted, and if You elect to email, You are aware that your personal information may be compromised. For the purposes of assessment of your symptoms, You will receive a questionnaire or series of questionnaires to your phone number, and email address, using a partner software (‘OutcomeMd’), to collect and track your symptoms. Your use of this software is optional. 

You understand that standard text messaging rates may apply as provided in your wireless plan. You have been advised that You may contact your carrier for pricing plans and details.

You understand that You may revoke your request for further communications via text or email at any time by notifying your Provider in writing. However, if You continue to communicate with the Practice or your Provider via text or email, the Practice and your Provider can assume that your consent remains valid.

Because e-mails sent over the Internet or texts sent without encryption are not secure, You understand the risks associated with e-mail and text messaging, including, without limitation, that e-mails and text messages could be intercepted by unknown third parties; e-mail content can be changed without the knowledge of the sender or receiver; backup copies of e-mail may still exist even after the sender and receiver have deleted the messages; and e-mail can contain harmful viruses and other programs.

Your Provider has recommended that You delete all text messages or emails as soon as possible after reviewing them to limit any unauthorized exposure.

Term, Termination, and Cancellation

This Agreement will commence on the Effective Date and will extend for one year thereafter. The Agreement shall be automatically renewed upon the anniversary of the Effective Date and each anniversary thereafter, unless terminated as outlined below. Patients are able to cancel at any point without obligation to continue. 

Cancellations. Please email [email protected] or message your Provider within the Remedy patient portal by 9am PT the business day before your scheduled billing date to cancel your account.  Remedy reserves the right not to refund any prepaid amounts due to cancellations.

If a patient wishes not to renew their annual membership, the patient must notify Remedy Psychiatry 30 days before the membership expires. Please note that patients are allowed to cancel at any point, but are only allowed to rejoin once every 12 calendar months and must pay the initial monthly fee for each time they rejoin.

In some cases, the Remedy Psychiatry medical team, nurse and/or physician may determine that You may require a higher level of care or alternate treatment for your benefit.  This may include, but is not limited to: discharge from care at Remedy Psychiatry and referral to in-person care by a local medical team, transfer to specialty care center (such as an addiction treatment center). 

Other Physicians

You acknowledge that your confirmation of engagement with this Agreement is strictly voluntary. This Agreement does not restrict or limit Your ability to receive professional services from other physicians and health care professionals.

 

Insurance Coverage of Fee 

The Practice makes no representations whatsoever that the fees paid under this Agreement are or are not covered by your Insurer. You will have the full and complete responsibility for any such determination and You understand and acknowledge that your Insurer may not pay for or reimburse You for the Concierge Service fee.

Insurance or Other Medical Coverage

This Agreement and the Practice’s provision of Concierge Services are not substitutes for health insurance or other health plan coverage (such as membership in an HMO). You acknowledge that the Practice has advised You to obtain or keep in full force your health insurance policy(ies) or plans in order to cover You and your family members for Medical Services and other healthcare costs. You acknowledge that this Agreement is not a contract that provides health insurance for You, and this Agreement is not intended to replace any insurance coverage provided to You by an Insurer and that Concierge Services are not intended to be billed to or covered by your Insurer. 

Severability 

If for any reason any provision of this Agreement shall be deemed, by a court of competent jurisdiction, to be legally invalid or unenforceable in any jurisdiction to which it applies, the validity of the remainder of the Agreement shall not be affected, and that provision shall be deemed modified to the minimum extent necessary to make that provision consistent with applicable law and in its modified form, and that provision shall then be enforceable. Modifications, Termination, Interruption and Disruptions You understand, agree and acknowledge that we may modify, suspend, disrupt or discontinue the Remedy Psychiatry platform, any part of the platform or the use of the platform, whether to all clients or to You specifically, at any time with or without notice to You. You agree and acknowledge that we will not be liable for any of the aforementioned actions or for any losses or damages that are caused by any of the aforementioned actions. The Remedy Psychiatry platform depends on various factors such as software, hardware and tools, either our own or those owned and/or operated by our contractors, suppliers, or other third-parties. While we make commercially reasonable efforts to ensure the platform’s reliability and accessibility, You understand and agree that no platform can be 100% reliable and accessible and so we cannot guarantee that access to the platform will be uninterrupted or that it will be accessible, consistent, timely or error-free at all time.

Amendment and updates to the Terms

We may modify these Terms regarding the Concierge and Medical Services from time to time. We will notify You of material changes by posting the amended terms on our Remedy Psychiatry platform and/or website. We can change the terms of this notice, and the changes will apply to all information we have about You. The new notice will be available upon request, in our office, and on our web site. If You do not agree with the proposed changes, You should discontinue your use of the Services. If You continue using the Services after the effective date, You will be bound by the updated Terms.

Unless otherwise specified by us, all modifications shall be effective upon posting. Therefore, You are encouraged to check the terms of this Agreement frequently. By using the Remedy Psychiatry platform and the Concierge Services after the changes become effective, You agree to be bound by such changes to the Agreement. If You do not agree to the changes, You must terminate your access to the Remedy Psychiatry platform and participation in the Concierge Services. Moreover, if federal, state, or local law or regulation (“Applicable Law”) requires this Agreement to contain provisions that are not expressly set forth in this Agreement, then, to the extent necessary, such provisions shall be incorporated by reference into this Agreement and shall be deemed a part of this Agreement as though they had been expressly set forth in this Agreement.

Assignment

This Agreement, and any rights You may have under it, may not be assigned or transferred by You. This Agreement, and any rights the Practice may have under it, may not be assigned or transferred to Your heirs, successors, or assignees. The Practice may freely transfer or assign this Agreement and/or any of its obligations hereunder.

Relationship of Parties

You and the Practice intend and agree that the Practice, in performing the Medical and Concierge Services under this Agreement, is an independent contractor, as defined by the guidelines promulgated by the United States Internal Revenue Service and/or the United States Department of Labor, and the Practice shall have exclusive control of its work and the manner in which it is performed.

Legal Significance

You acknowledge that this Agreement is a legal document and creates certain rights and responsibilities. You also acknowledge that You have had a reasonable time to seek legal advice regarding the Agreement and have either chosen not to do so or have done so and are satisfied with the terms and conditions of the Agreement.

Notice

All written notices are deemed served when sent if sent to the e-mail address of the party appearing in Appendix 2 by email.

Governing Law

This Agreement shall be governed and construed under the laws of California. This Agreement shall be construed without regard to any presumptions or rules requiring construction against the party causing the instrument to be drafted.

Headings

Captions in this Agreement are used for convenience only and shall not limit, broaden, or qualify the text.

Entire Agreement

This Agreement contains the entire agreement between the parties regarding the subject matter of this Agreement, and supersedes all prior oral and written understandings and agreements regarding the subject matter of this Agreement. If any provision of this Agreement is held by a court of competent jurisdiction to be illegal, invalid, unenforceable, or otherwise contrary to law, the remaining provisions of this Agreement will remain in full force and effect.

APPENDIX 1: INFORMED CONSENT FOR TELEHEALTH, TREATMENT AND MEDICATION PRESCRIPTIONS

 

Consent to Telehealth

Background on Telehealth

Telehealth involves the use of electronic communications technologies to enable the transfer of medical/health and other information between a health care provider and patient who are in different locations. Telehealth technologies may include interactive two-way audio and video, interactive audio, remote monitoring, patient medical records, medical images, e-mail, output data from medical devices, and sound and video files. Information conveyed using telehealth may be used for the diagnosis, treatment, follow-up and/or education of patients.

The types of electronic transmissions that may occur via telehealth include, but are not limited to:

• Appointment scheduling;
• Completion, exchange, and review of medical intake forms and other clinically relevant information (for example: health records; images; output data from medical devices; sound and video files; diagnostic and/or lab test results) between You and your Provider via asynchronous communications;
• Two-way interactive audio in combination with store-and-forward communications; and/or two-way interactive audio and video interaction;
• Treatment recommendations by your Provider based upon such review and exchange of clinical information;
• Delivery of a consultation report with a diagnosis, treatment, and/or prescription recommendations, as deemed clinically relevant;
• Prescription refill reminders (if applicable); and/or
• Other electronic transmissions for the purpose of rendering clinical care to You.

Expected Benefits of Receiving Medical Services via Telehealth

• Improved access to medical care by enabling You to consult with your physician remotely.
• More efficient medical evaluation and management.
• Obtaining the expertise of a distant specialist.

Possible Risks of Receiving Medical Services via Telehealth

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

• In rare events, your Provider may determine that the transmitted information is of inadequate quality to allow for appropriate medical decision making, thus necessitating a rescheduled telehealth consult or an in-person meeting with your local primary care doctor.
• Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment, or Provider availability.
• In the event of an inability to communicate as a result of a technological or equipment failure, please contact the Practice at 415-403-2156 or [email protected].
• In very rare events, security protocols could fail, causing a breach of privacy or loss of personal medical information.
• A lack of access to complete medical records may result in inaccurate and/or incomplete medical advice, including adverse drug interactions or allergic reactions or other judgment errors.
• Receiving Services on a public access computer, or one that is on a shared network (e.g., a work computer), or using auto-fill user names and passwords, may result in privacy and/or security breaches of your health information.
• There may be other risks that are currently not known or not material enough to include here.

Service Limitations

• • The primary difference between telehealth and direct in-person service delivery is the inability to have direct, physical contact with the patient. Accordingly, some clinical needs may not be appropriate for a telehealth visit and your Provider will make that determination.

• OUR PROVIDERS DO NOT ADDRESS MEDICAL EMERGENCIES. IF YOU BELIEVE YOU ARE EXPERIENCING A MEDICAL EMERGENCY, YOU SHOULD DIAL 9-1-1 AND/ OR GO TO THE NEAREST EMERGENCY ROOM. 

• Our Providers are an addition to, and not a replacement for, your local primary care provider. Responsibility for your overall medical care should remain with your local primary care provider if You have one, and the Practice strongly encourages You to locate a primary care provider if You do not have one.
• The Practice does not have any in-person clinic locations.

Privacy and Security Measures

All existing privacy and security protections under federal and California law apply to information used or disclosed during a telehealth encounter. The electronic communication systems we use 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. All services delivered to the patient through telehealth will, to the Practice’s knowledge, be delivered over a secure connection that complies with the requirements of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”).

Alternatives to Telehealth

As an alternative to a telemedicine consultation, You can make an in-person appointment with your primary care physician or a specialty provider, or choose not to receive treatment at all.

Consent to Treatment

Medical Practice Consent

You have the right, as a patient, to be informed about your condition and any recommended medical or diagnostic procedure to be used so that You may make the decision whether or not to undergo diagnosis or treatment after knowing the risks and hazards involved. This disclosure is not meant to scare or alarm You; it is simply an effort to make You better informed, so You may give or withhold your consent to diagnosis or treatment.

By signing this form, You voluntarily understand, acknowledge, and agree to the following with respect to medical services rendered by Physicians, Nurse Practitioners, employees, agents, and other licensed medical professionals on behalf of Remedy Psychiatry.

 

Description/Nature of Practice

The Practice provides psychiatric services which includes medication management and psychotherapy in a traditional or telehealth format. Psychiatry is the branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional and behavioral disorders. Psychotherapy includes talk therapy, which is a way to help people with a broad variety of mental illnesses and emotional difficulties. Psychotherapy can help eliminate or control troubling symptoms so a person can function better and can increase well-being and healing. Psychotherapy is often used in combination with medication to treat mental health conditions. In some circumstances, medication may be clearly useful and in others, psychotherapy may be a better option. For many people combined medication and psychotherapy treatment is better than either alone.

The Practice’s procedures include:

• recommendation of food and dietary supplements/herbal products
• ordering of diagnostic/laboratory evaluations 
• medication prescription and management
• psychotherapy

You voluntarily consent to and authorize these procedures, as well as those additional procedures which are advisable in your Provider’s professional judgment.

The Practice’s Providers abide by necessary national medical, psychiatric and nursing standards of care and take these very seriously to ensure that You are always treated fairly and with the utmost respect. You are aware that it is normal to sometimes go through periods of time when You may feel emotional discomfort or temporary worsening of symptoms. Throughout our work together, Remedy encourages patients to talk with us about any questions or concerns You may have about the therapeutic relationship. You always have the right to refuse treatment, request changes in treatment or to decline to continue treatment at any time. You have the right to receive assistance in referral to alternative services if You do not feel the practice can be of further assistance to me. This may also happen if the Practice’s staff believes a patient’s level of need for care is beyond what the practice can provide.

Medications

During the course of your care, if a medication is suggested to You by your Provider, You will be orally informed of the risks, benefits, side effects and alternatives to that medication.

Given that your Provider is licensed to practice medicine, prescribe and treat patients in California, medications will be prescribed to that state. If You are to travel to another state or country, You are responsible for planning ahead to request that your medication be sent to your California pharmacy for early fill so as to have sufficient medication during your travel. If You run out of medication, or it is lost or stolen, your Provider may not be able to send a prescription for a medication refill in another state or country. In this case, it is recommended that You seek local care through an urgent care or emergency room to obtain your medication.

Choosing to take medication is a serious commitment. With any medication use, your conditions may not initially improve or could temporarily get worse.  It is the Provider’s responsibility to educate You on the pertinent potential risks and benefits of medication therapies. There can be associated side effects which will vary depending on the medication. These side effects can range from minor to life threatening. Always notify your Provider of any side effects or problems with medications You might be experiencing. Direct risks also include adverse herb/drug interactions or allergic reactions. You agree to advise the Practice and your Provider if You experience the above side effects.

The Practice Providers will do all they can to mitigate the risks and maximize the benefits of medication therapies. In order to do such, please assume that the Practice must see You in appointments to prescribe your medication. It is at the discretion of the Provider whether they can refill your medication in the context of an initial encounter, a no show or significant tardiness with factors considered including risks and benefits of not providing the medication. Patients/clients are responsible to outreach the practice in cases of no shows, lost medication or to request medication refills. The Practice is not required to refill lost or stolen medication and may require additional measures in order to refill lost or stolen medication.

Some medications may interact with other medications or be particularly risky for individuals with some health conditions. By consenting to treatment, You authorize  the Practice to obtain your medication history as part of the services You are requesting. It is at the discretion of the Provider whether the Provider may initiate or continue a medication regimen without completed indicated lab work or consent for collateral information from an outside therapist or medical provider. If a Provider is unable to receive necessary lab work, they may not be able to continue certain medications. A patient/client will never be required to give consent for collateral (outside) contacts, though refusal or inability to provide such may limit the Provider’s ability to prescribe certain medications.

Dietary Supplements—Risk, Benefits & Alternatives

Dietary supplements are marketed for general well-being, or as intended to affect the normal structure or function of the human body. Thus, although Provider’s may recommend dietary supplements with a specific therapeutic purpose in mind, manufacturers and distributors are prohibited from making drug or therapeutic claims for dietary supplements, and their use in clinical practice is chiefly designed to support general well-being or certain aspects of metabolic function.  While most dietary supplements are generally considered safe, efficacy has not conclusively been established; and in some cases, adverse reactions can occur if the patient is concurrently using pharmaceutical medications (drugs). For this reason, it is important to keep all of your healthcare providers fully informed about all medications and dietary supplements You may be taking.

Remote Prescribing of Controlled Substances

California Business and Professions Code Section 2242 prohibits a medical professional from prescribing a controlled substance without an in-person medical evaluation.  However, due to the COVID-19 pandemic, as of January 31, 2020, the Drug Enforcement Administration (“DEA”) announced that it will allow DEA registered practitioners to issue prescriptions for controlled substances to patients for who they have not conducted an in-person medical evaluation, so long as certain conditions are met.  This temporary change to the law shall remain in effect for the duration of the public health emergency.  As such, it is possible that this allowance will be reversed and patients that have initiated care with Remedy may need to arrange an in-person appointment with a local medical team in order to continue their medications.

Prescription Monitoring Program

You understand that Providers are required by law to check prescription monitoring databases when prescribing controlled substances. In preparation for your visit and at any time throughout your care, the Practice or Provider’s may check these databases in all 50 states. You also understand because this is required by law, your consent is not required.

Off-Label Use

You understand that the Practice Provider’s may prescribe medications for uses other than those indicated by the drug manufacturer and approved by the federal Food and Drug Administration (off-label use).  In such case, no one can be fully aware of all possible side effects and complications.  The details of such off-label use including expected benefits, material risks and alternatives, will been explained to You in terms You understand.  You will inform the Practice of all known allergies, and of all medications You are currently taking.  

BY CLICKING ACCEPT, I ACKNOWLEDGE THAT I UNDERSTAND AND AGREE WITH THE FOLLOWING:

1. I give my informed consent to receive Medical Services through telehealth technology from the Practice, and its Providers, Affiliates, and Associates for myself or for the individual for whom I am a parent or legal guardian. This medical care may include services related to my health (or the identified person) and may include (but not limited to) preventative care, diagnostic testing, therapeutic treatments, medication prescribing and psychotherapy. This consent includes contact and discussion with other health care professionals for care and treatment, as deemed necessary by my Provider. 
2. I have been given an opportunity to review the credentials of the Practice’s Providers and to select a Provider prior to any initial consultation. I understand I may be assigned a different Provider from my initial selection based on my specific care needs and/or general Provider availability, and I will always have the right to request a different Provider at any time. 
3. There is no guarantee that I will be treated by a Provider or receive a prescription for any medication. The Practice’s Providers reserve the right to deny care for potential misuse of the Services or for any other reason if, in the professional judgment of the Practice or a Provider, the provision of Services is not medically or ethically appropriate. 
4. 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. The Practice and/or my Provider have explained the alternatives to my satisfaction. 
5. Telehealth may involve electronic communication of my personal medical information to the Practice, its Providers, Affiliates and Associates, or other healthcare providers who may be located in other areas, including in other states. 
6. It is my duty to inform the Practice and my Provider of interactions regarding my care that I may have with other healthcare providers to ensure my Provider has a full clinical picture when making treatment decisions. 
7. Third-party services such as those involving physical tests may be conducted by individuals at a testing facility such as a laboratory at the direction of my Provider. I understand these services are not covered by my Membership fee and may be billed separately. 
8. I accept responsibility for any copayments, coinsurances, deductibles, and/or non-covered services that apply to my telehealth visit. More information on the costs of services can be found at: https://remedypsychiatry.com/pricing/
9. I have the right to withhold or withdraw my consent to treatment or the use of telehealth in the course of my care at any time. I understand the health risks associated with ending my treatment.
10. I may suspend or terminate access to the Services at any time for any reason or for no reason.
11. I understand that if I am experiencing a medical emergency, that I will be directed to dial 9-1-1 immediately and that the Practice and its Affiliates, Associates and Providers may not be able to connect me directly to any local emergency services.
12. I have the right to inspect all information obtained and recorded in the course of a telehealth interaction, including my medical record, and may receive copies of this information for a reasonable fee.
13. I understand that my healthcare information may be shared with other individuals for scheduling, treatment and/or billing purposes. In addition, I understand that persons other than my Provider may be present during the consultation in order to operate the telehealth technologies. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/examination that are personally sensitive to me; (2) ask non-medical personnel to leave the telehealth examination; and/or (3) terminate the consultation at any time. I will also notify my Provider if I would like my information to be shared with another health care provider, such as my primary care provider.
14. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telehealth, and that no information obtained in the use of telehealth that identifies me will be disclosed to other entities without my consent.
15. I may expect the anticipated benefits from the use of telehealth in my care, but that no results can be guaranteed or assured.
16. There is a risk of technical failures during the telehealth encounter beyond the control of the Practice or its Providers, Affiliates and/or Associates. I agree to hold harmless the Practice, its Providers, Affiliates, and Associates for delays in evaluation or for information lost due to such technical failures.
17. In the event of any problem with the Services or the online platform used to access the Services, I agree that my sole remedy is to cease using the platform or terminate access to the Services. Under no circumstances will the Practice, its Providers, Affiliates, and/or Associates be liable in any way for the use of telehealth services, including but not limited to, any errors or omissions in content or infringement by any content on the website of any intellectual property rights or other rights of third parties, or for any losses or damages of any kind arising directly or indirectly out of the use of, inability to use, or the results of use of the website, and any website linked to the website, or the materials or information contained on any or all such websites. I agree that I will not hold the Practice, including its subsidiaries and affiliates, or the Practice’s Providers, Affiliates and Associates liable for any punitive, exemplary, consequential, incidental, indirect or special damages (including, without limitation, any personal injury, lost profits, business interruption, loss of programs or other data on my computer or otherwise) arising from or in connection with my use of the website whether under a theory of breach of contract, negligence, strict liability, malpractice or otherwise, even if we or they have been advised of the possibility of such damages.
18. The Practice makes no representation that materials on its website or online telehealth platform are appropriate or available for use in any other location. I understand that if I access these services from a location outside of the United States, that I do so at my own risk and initiative and that I am ultimately responsible for compliance with any laws or regulations associated with my use.
19. I am aware that I have a right to, and can request a copy of this consent form.
20. Before the commencement of my initial consultation with Remedy Psychiatry, Inc., Affiliates, and/or Associates, I had an opportunity to discuss the above with my practitioner and all of my questions have been answered to my satisfaction.

APPENDIX 2: DISCLOSURES

All physicians and nurses on Remedy Psychiatry hold professional licenses issued by the professional licensing boards in the states where they practice. You can report a complaint relating to services provided by a Treating Provider by contacting the professional licensing board in the state where the services were received. In a professional relationship, sexual intimacy is never appropriate and should be reported to the board that licenses, registers, or certifies the licensee.

You can find the contact information for each of the state professional licensing boards governing medicine on the Federation of State Medical Boards website at:

• http://www.fsmb.org/state-medical-boards/contacts

Any clinical records created as a result of your use of the Site will be securely maintained by Remedy Psychiatry on behalf of your Treating Provider(s) for a period that is no less than the minimum number of years such records are required to be maintained under state and federal law, and which is typically at least six years.

Please report any violations of these New Patient Agreement and Informed Consent to [email protected]

 

APPENDIX 3: PRIVACY POLICY

 

Notice of Privacy Practices

Our Privacy Obligations

The law requires us to maintain the privacy of certain health information called “Protected Health Information” (“PHI”). Protected Health Information is the information that you provide us or that we create or receive about your health care. The law also requires us to provide you with this Notice of our legal duties and privacy practices. When we use or disclose (share) your Protected Health Information, we are required to follow the terms of this Notice or other notice in effect at the time we use or share the PHI. Finally, the law provides you with certain rights described in this Notice. Furthermore, we are required to notify you following a breach of unsecured PHI.

Please note that if you choose to communicate with Remedy Psychiatry, your Nurse or Doctor, outside of the Remedy Psychiatry provided HIPAA encrypted platforms of IntakeQ, Drchrono, Doxy, iplum, OutcomeMD or the telehealth video platform, such as but not limited to: by texting, phone call, FaceTime or other means, your health information will not be protected and may be subject to interception. OutcomeMD is a fully HIPAA compliant platform that will securely send you assessment questions known as Patient Reported Outcome Measures to your email and/or text message. All data is de-identified in motion and rest. 

Ways We Can Use and Share Your PHI Without Your Written Permission (Authorization)

In many situations, we can use and share your PHI for activities that are common in many hospitals and clinics. In certain other situations, which we will describe in Section 4 below, we must have your written permission (authorization) to use and/or share your PHI. We do not need any type of permission from you for the following uses and disclosures:

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND SHARED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This Notice describes the privacy practices of Remedy Psychiatry, Inc.. It applies to the health care and related services you receive from Remedy Psychiatry, Inc., and/or its Providers, Affiliates, and/or Associates. For purposes of this Notice, Remedy Psychiatry, Inc., Affiliates, and/or Associates will be referred to herein as “we” or “us.” We will share your health information among ourselves to carry out our treatment, payment, and health care operations.

Uses and Disclosures for Treatment, Payment and Health Care Operations

We may use and share your PHI to provide “Treatment,” obtain “Payment” for your Treatment, and perform our “Health Care Operations.” These three terms are defined as:

Definitions

• Treatment. We use and share your PHI to provide care and other services to you–for example, to diagnose and treat your injury or illness. In addition, we may contact you to provide appointment reminders or information about treatment options. We may tell you about other health-related benefits and services that might interest you. We may also share PHI with other doctors, nurses, and others involved in your care. We share your PHI with the pharmacy in order to prescribe medication to you.
• Payment. We may use and share your PHI to receive payment for services that we provide to you. For example, we may share your PHI to request payment and receive payment, or coverage of your prescribed medications, from Medicare, Medicaid, your health insurer, HMO, or other company or program that arranges or pays the cost of some or all of your health care (“Your Payor”) and to confirm that Your Payor will pay for health care, or your prescription medication. As another example, we may share your PHI with the person who you told us is primarily responsible for paying for your Treatment, such as your spouse or parent.
• Health Care Operations. We may use and share your PHI for our health care operations, which include management, planning, and activities that improve the quality and lower the cost of the care that we deliver. For example, we may use PHI to review the quality and skill of our physicians, nurses, and other health care providers. However, you have the right to restrict disclosure to a health plan for healthcare services for which you pay in full out of pocket (excluding a deductible).
• Business Associates. In addition, we may share PHI with certain others who help us with our activities, including those we hire to perform services.

Your Other Health Care Providers

We may also share PHI with your doctor and other health care providers when they need it to provide Treatment to you, to obtain Payment for the care they give to you, to perform certain Health Care Operations, such as reviewing the quality and skill of health care professionals, or to review their actions in following the law.

Disclosure to Relatives, Close Friends and Your Other Caregivers

We may share your PHI with your family member/relative, a close personal friend, or another person who you identify if we: (1) first provide you with the chance to object to the disclosure and you do not object; (2) reasonably infer that you do not object to the disclosure; or (3) obtain your agreement to share your PHI with these individuals. If you are not present at the time we share your PHI, or you are not able to agree or disagree to our sharing your PHI because you are not capable or there is an emergency circumstance, we may use our professional judgment to decide that sharing the PHI is in your best interest. We may also use or share your PHI to notify (or assist in notifying) these individuals about your location and general condition.

Public Health Activities

We are required or are permitted by law to report PHI to certain government agencies and others. For example, we may share your PHI for the following:

• to report health information to public health authorities for the purpose of preventing or controlling disease, injury, or disability;
• to report abuse and neglect to government authorities, including a social service or protective services agency, that are legally permitted to receive the reports;
• to report information about products and services to the U.S. Food and Drug Administration;
• to alert a person who may have been exposed to a communicable disease or may otherwise be at risk of developing or spreading a disease or condition;
• to report information to your employer as required under laws addressing work-related illnesses and injuries or workplace medical surveillance; and
• to prevent or lessen a serious and imminent threat to a person for the public’s health or safety, or to certain government agencies with special functions such as the State Department.

Health Oversight Activities

We may share your PHI with a health oversight agency that oversees the health care system and ensures the rules of government health programs, such as Medicare or Medicaid, are being followed.

Judicial and Administrative Proceedings

We may share your PHI in the course of a judicial or administrative proceeding in response to a legal order or other lawful process.

Law Enforcement Purposes

We may share your PHI with the police or other law enforcement officials as required or permitted by law or in compliance with a court order or a subpoena.

 

Decedents

We may share PHI with a coroner or medical examiner as authorized by law. We may share your PHI with a family member who was involved in your care or payment for your care prior to death, unless such disclosure would be inconsistent with any prior expression you have communicated to us. Under federal, the privacy rights described herein will expire fifty years after your death.

Workers’ Compensation

We may share your PHI as permitted by or required by state law relating to workers’ compensation or other similar programs.

Disaster Relief

We may share your PHI to a public or private entity authorized by law or by its charter to assist in disaster relief efforts.

As Required by Law

We may use and share your PHI when required to do so by any other law not already referred to above.

USES AND DISCLOSURES REQUIRING YOUR WRITTEN PERMISSION (AUTHORIZATION)

Use or Disclosure with Your Permission (Authorization)

For any purpose other than the ones described above, we may only use or share your PHI when you grant us your written permission (authorization). For example, you will need to give us your permission before we send your PHI to your life insurance company or disability insurance company.

Marketing

We must also obtain your written permission (authorization) prior to using your PHI to send you any marketing materials paid for by a third party. However, we may communicate with you over the Remedy telehealth platform, by text, by email or face to face about products or services related to your treatment, case management, care coordination, or alternative treatments, therapies, health care providers, or care settings. If you consent to receive such communications, you are welcome to ‘opt-out’ of Remedy marketing, educational and promotional emails or texts at any point in time by notifying Remedy, while staying subscribed to the Remedy care subscription. 

We may not sell your PHI without your written authorization.

Uses and Disclosures of Your Highly Confidential Information

Federal and state law requires special privacy protections for certain highly confidential information about you (“Highly Confidential Information”), including: (1) any portion of your PHI that is kept in psychotherapy notes; (2) about mental health and developmental disabilities services; (3) about alcohol and drug abuse prevention, treatment and referral; (4) about HIV/AIDS testing, diagnosis or treatment; (5) about sexually transmitted disease(s); (6) about genetic testing; (7) about child abuse and neglect; (8) about domestic abuse of an adult with a disability; (9) about sexual assault; or (10) In Vitro Fertilization (IVF). Before we share your Highly Confidential Information for a purpose other than those permitted by law, we must obtain your written permission.

Your Rights Regarding your Protected Health Information

For Further Information; Complaints

If you want more information about your privacy rights, are concerned that we have violated your privacy rights, or disagree with a decision that we made about access to your PHI, you may contact our HIPAA Privacy Officer. You may also file written complaints with the Office for Civil Rights (“OCR”) of the U.S. Department of Health and Human Services by sending a letter to 200 Independence Avenue, S.W., Washington D.C. 20201, calling 1-877-796-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints. We will not take any action against you if you file a complaint with us or with the OCR.

Right to Receive Confidential Communications

You may ask us to send PHI to a different location than the address that you gave us, or in a special way, or to contact you at a different phone number. You will need to ask us in writing. For example, you may ask us to send a copy of your medical records to a different address than your home address. We will accept all reasonable requests.

Right to Revoke Your Written Permission (Authorization)

You may change your mind about your authorization or any written permission regarding your PHI by giving or sending a written “revocation statement” to the HIPAA Privacy Officer at the address below. The revocation will not apply to the extent that we have already taken action where we relied on your permission.

Right to Inspect and Copy Your Health Information

You may request copies (for a reasonable fee) and/or access to your medical record file, billing records, and other records. You have a right to a copy of your records if your provider deems that it is in your best interest and would not contribute to worsening of your mental health, if part of a “designated record set” in electronic format, as reasonably available. You can review your medical records and/or ask for hard copies. Under limited circumstances, we may deny you access to a portion of your records. This denial is used if it is determined by your medical team, that reading your medical record may incur further mental health distress. In this case, you may elect to have a summary of your record, or entire record, sent to a new medical treatment team or physician to continue your care with. If you want to access your records, you may obtain a record request form from Remedy Psychiatry, Inc., Affiliates, and/or Associates and return the completed form to the Privacy Officer.

Right to Amend Your Records

You have the right to request that we amend PHI maintained in medical record files, billing records, and other records used to make decisions about your Treatment and payment for your Treatment. If you want to amend your records, you may obtain an amendment request form from the HIPAA Privacy Officer. After which, you can return the completed form to the HIPAA Privacy Officer. We will comply with your request unless we believe that the information that would be amended is correct and complete or that other circumstances apply. In the case of a requested amendment concerning information about the Treatment of a mental illness or developmental disability, you have the right to appeal to a state court our decision not to amend your PHI.

Right to Receive an Accounting of Disclosures

You may ask for an accounting of certain disclosures of your PHI made by us. These disclosures must have occurred before the time of your request, and we will not go back more than six (6) years before the date of your request. If you request an accounting more than once during a twelve (12) month period, we will charge you based on the rate sheet. Direct your request for an accounting to the HIPAA Privacy Officer.

Right to Request Restrictions

You have the right to ask us to restrict or limit the PHI we use or disclose about you for treatment, payment, or health care operations. With one exception, we are not required to agree to your request. If we do agree, we will comply unless the information is needed to provide emergency treatment. Your request for restrictions must be made in writing and submitted to the HIPAA Privacy Officer at the address below. We must grant your request to a restriction on disclosure of your PHI to a health plan if you have paid for the health care item in full out of pocket.

Right to Receive a Copy of this Notice

Upon written request, you may obtain a copy of this Notice, even if you have agreed to receive the notice electronically. Please send any such request to the HIPAA Privacy Officer at the address or email address listed below.

Effective Date

This Notice is effective as July 15, 2020.

 

Right to Change Terms of this Notice

We may change the terms of this Notice at any time. If we change this Notice, we may make the new notice terms effective for all Protected Health Information that we maintain, including any information created or received prior to issuing the new notice. If we change this Notice, we will post the new notice in common areas throughout our facility, and on our Internet site at www.Remedy Psychiatry.com. You also may obtain any new notice by contacting the Privacy Officer.

Federal & State Law

Federal and state laws require Remedy Psychiatry, Inc., Affiliates, and/or Associates to protect your medical information and federal law requires Remedy Psychiatry, Inc., Affiliates, and/or Associates to describe to you how we handle that information. When federal and state privacy laws differ, and the state law is more protective of your information or provides you with greater access to your information, then state law will override federal law.

Questions or Concerns: HIPAA Privacy Officer Contact Information

You may contact the Privacy Officer for additional information:

Kirsten Thompson 

Email: [email protected]

Address: (Mailing address only)

200 S. Barrington Ave, PO Box 492124

Los Angeles CA 90049-9998

Phone: 818-514-9033

APPENDIX 4: PATIENT BILL OF RIGHTS

Many states have adopted a patient bill of rights applicable to patients of physicians and/or hospitals and other health care facilities. Some of those states require that physicians provide a copy of the bill of rights to their patients. The portion of the bill of rights that is relevant to the Service is provided to you here on behalf of Remedy Psychiatry, Inc., Affiliates, and/or Associates. Please note that it includes patient responsibilities as well.

• A patient has the right to be treated with courtesy and respect, with appreciation of his or her individual dignity, and with protection of his or her need for privacy.
• A patient has the right to a prompt and reasonable response to questions and requests within the context of the Service.
• A patient has the right to know who is providing medical services and who is responsible for his or her care.
• A patient has the right to know what patient support services are available, including whether an interpreter is available if he or she does not speak English.
• A patient has the right to know what rules and regulations apply to his or her conduct.
• A patient has the right to be given information by the health care provider concerning diagnosis, planned course of treatment, alternatives, risks, and prognosis.
• A patient has the right to refuse any treatment provided via the Service unless otherwise required by law.
• A patient has the right to receive a copy of a reasonably clear and understandable, itemized bill and/or receipt and, upon request, to have the charges explained.
• A patient has the right to impartial access to medical treatment or accommodations, regardless of race, national origin, religion, handicap, or source of payment, subject to the technical limitations of the Service.
• A patient has the right to express grievances regarding any violation of his or her rights, as stated in state law, through the grievance procedure of the health care provider which served him or her and to the appropriate state licensing agency.
• A patient is responsible for providing to the Provider, to the best of his or her knowledge, accurate and complete information about present complaints, past illnesses, hospitalizations, medications, and other matters relating to his or her health.
• A patient is responsible for reporting unexpected changes in his or her condition to the Provider.
• A patient is responsible for reporting to the Provider whether he or she comprehends a contemplated course of action and what is expected of him or her.
• A patient is responsible for following the treatment plan recommended by the Provider.
• A patient is responsible for his or her actions if he or she refuses treatment or does not follow the Provider’s instructions.

For informational purposes only, a link to the federal Centers for Medicare and Medicaid Services (CMS) Open Payments web page is provided here. The federal Physician Payments Sunshine Act requires that detailed information about payment and other payments of value worth over ten dollars ($10) from manufacturers of drugs, medical devices, and biologics to physicians and teaching hospitals be made available to the public. The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov.

State Specific Notifications

Remedy Psychiatry’s services are only offered in California at this time.  You agree that you are domiciled in and physically present in California and agree to receive care by Remedy Psychiatry within the state of California. You understand that your practitioner is licensed in the state of California, and if you move or seek temporary or permanent residence in another state or country, your Remedy Psychiatry nurse or physician may not be licensed in that state and you may need to obtain alternative and ongoing care, and medication-prescribing services, outside of Remedy Psychiatry.

For California Residents

• You or your legal representative retains the option to withhold or withdraw consent to receive health care services via the Service at any time without affecting your right to future care or treatment nor risking the loss or withdrawal of any benefits to which you or your legal representative would otherwise be entitled.
• All existing confidentiality protections apply.
• All existing laws regarding patient access to medical information and copies of medical records apply.
• Dissemination of any of any of your identifiable images or information from the telehealth interaction to researchers or other entities shall not occur without your consent.
• All provisions herein, including your informed consent to receive services via the Service are for the benefit of the treating provider as well as for your benefit.
• Medical doctors are licensed and regulated by the Medical Board of California, (800) 632-2322, www.mbc.ca.gov

State Specific Direct Primary Care (“DPC”) Requirements

For California Residents

Remedy Psychiatry shall charge the monthly fee of $189 for your first month if you are an adult age of 18 or older, or $209 for your first month for patients under the age of 18, and $99 per month starting in your second month if you are an adult age 18 or older, or $109 starting in your second month if you are under the age of 18. Your flat monthly fee is the maximum amount you will pay, excluding billing for no-show appointments, late cancellation appointments, or fees billed for completing documentation. All text messages and telephone calls will be considered as follow-up to the initial and subsequent face-to-face video chat appointments. Your credit card will be charged $189 for your first month if you are an adult age of 18 or older, or $209 for your first month for patients under the age of 18, and $99 per month starting in your second month and every month after if you are an adult age 18 or older, or $109 starting in your second month if you are under the age of 18. This Agreement is not a health benefit plan as otherwise described by law as it only pertains to a limited set of services provided through Remedy Psychiatry. This Agreement does not satisfy minimum essential coverage standards for health insurance under state or under the federal Patient Protection and Affordable Care Act, as currently enacted or hereafter amended, 26 U.S.C. 5000a, and there may be tax consequences for those who do not have not qualified comprehensive health coverage in addition to this Agreement. If this Agreement terminates for any reason, and you have not already purchased health care insurance coverage that will satisfy state and federal minimum coverage standards, you will not be able to purchase new individual health insurance until the next health insurance open enrollment period has begun. Remedy Psychiatry only covers those services specifically identified in this Agreement when delivered or arranged by Remedy Psychiatry providers according to the terms of this Agreement. Remedy Psychiatry providers may refer a patient to a non-Remedy Psychiatry provider for medical services, prescription drugs or supplies, but in that circumstance, you will need to contact your health insurance provider and follow the health plan’s managed care procedures in order to obtain coverage for the referred services, prescription drugs or supplies under the health plan’s benefits. Certain services identified in this Agreement may already be covered under your health plan at no additional cost when provided by non-Remedy Psychiatry providers. You will need to contact your health plan to understand the benefits and limitations of your health insurance plan and any overlap between the services offered under this Agreement and the coverage under your health insurance plan.

 

Outside Professionals on the Platform

From time to time, outside medical professionals (doctors, nutritionist, dietitians for example) & organizations may contract with Remedy Psychiatry, Inc., Affiliates, and/or Associates Physician Group (and affiliated physician groups) in order to use our technology to communicate with our patients). In this regard, Remedy Psychiatry, Inc., Affiliates, and/or Associates Inc. operates a technology service provider for those professionals under a separate agreement, and it’s the responsibility of the partner to enter into a separate agreement with those patients they interact with on the Remedy Psychiatry, Inc., Affiliates, and/or Associates platform.

APPENDIX 5: AGREEMENT TO USE OF THE PLATFORM

The following are the IntakeQ,Drchrono, Onpatient, and iPlum Terms and Conditions of Use which govern your access and use of our online platforms through which medical treatment and counseling may be provided (collectively, the “Platform”). The Platform may be provided or be accessible via multiple websites or applications whether owned and/or operated by us or by third parties, including, without limitation, the website https://www.Remedy Psychiatry.com and its related apps.

By accessing or using the Platform, you are agreeing to each of the below Terms and Conditions of Use. You should read these separate Terms and Conditions of Use. If you do not agree to be bound by these separate Terms and Conditions of Use, you must not access the Platform.

When the terms “we”, “us”, “our” or similar are used in this Agreement, they refer to any company that is affiliated with, and/or owns and operates the Platform, including but not limited to Remedy Psychiatry, Inc., P.C., and Remedy Psychiatry, Inc. (the “Company”).

For the most up to date Terms and Conditions of Use, please read and refer to the below links for each aspect of the Platform:

IntakeQ:

https://intakeq.com/terms

DrChrono:

https://www.drchrono.com/ehr-emr/terms/

iPlum:

https://iplum.com/privacy/#:~:text=Privacy%20%26%20Terms%20of%20Use%201%20Remedies%3A%20iPlum,Media%2C%20Reviews%20Posting%20…%206%20Customer%20Agreements%3A%20

OutcomeMD:

https://outcomemd.com/terms-of-use

APPENDIX 6: CONCIERGE SERVICE

Under the Agreement, patients paying a monthly fee are entitled to receive the following Concierge Services in exchange for the fee listed. The subscription payment terms describing these Subscription services are always applicable to patients not using health insurance to pay for Services, and sometimes applicable to those who are using health insurance to pay, at least in part, for the Services. IF YOU DECIDE TO USE HEALTH INSURANCE TO PAY FOR YOUR SERVICES AND HAVE QUESTIONS ABOUT YOUR FINANCIAL OBLIGATIONS, YOU SHOULD CONTACT YOUR INSURANCE PROVIDER DIRECTLY AND BEFORE ENROLLING FOR SERVICES.

• Connection to the same Nurse Practitioner via video appointments and messaging through the Platform for questions. 
• Same Day/Next Day Appointments.
• When Patient requests to schedule an appointment, a reasonable effort shall be made to schedule an appointment with the same Nurse on the same day or within 48 business hours.
• Electronic Medical Record and the Platform for communication and monitoring for health data.
• Remedy Psychiatry will provide information obtained via the Platform(Drchrono, OutcomeMD IntakeQ) to the medical team in a comprehensive manner regarding the patient’s health status and communications.

Concierge Services Patient Warning. Patient understands and agrees that email and the internet should never be used to access medical care in the event of an emergency, or any situation that Patient could reasonably expect may develop into an emergency. Patient agrees that in such situations, when a Patient cannot speak to a Nurse immediately in person or by telephone, that Patient shall call 911 or the nearest emergency medical assistance provider and follow the directions of emergency medical personnel.