Consent to Telehealth services, Informed Consent for Medications, Consent for Coaching Services and Privacy Policies.
(For those 13-17 years of age, please also see Teen Consent for additional terms.)
Bend Health Psychiatric Services New England, P.A. and each of the affiliated physician practices listed below * (Bend Health) each provide a telemedicine platform through which you can work with a psychiatry, PMHNP’s, RN’s and other mental health providers including social workers and MH coaches to provide you with mental health services. The purpose of this form is to provide you with important information about your telemedicine services, and obtain your consent to participate in a telemedicine encounter as an acceptable mode of delivering your health care services with one of Bend Health’s mental health providers via various synchronous and asynchronous technologies (telemedicine) as appropriate per case.
By clicking "I ACCEPT", you understand and agree that:
1. Nature of the Telemedicine Consultation.
2. Limits of Telemedicine Consultation. Telemedicine will be used by a mental health provider to deliver therapy services to you. Telemedicine may not be as complete as face-to-face treatment and is not intended to replace a full medical face-to-face evaluation by a mental health provider. You may benefit from telemedicine services; however, results cannot be guaranteed or assured. The Bend Health practitioner will determine whether or not it is appropriate to treat you via a telemedicine encounter. By accepting these terms, you consent to receive Bend Health’s services via telemedicine technologies as described above.
3. Medical Information and Records. All existing laws regarding the confidentiality of your medical information apply to this telemedicine visit. Disclosure of any patient-identifiable images, audio recordings, or other information from this telemedicine interaction to other entities shall not occur without your consent, unless permitted by applicable law.
4. Right to Care. You are under no obligation to use telemedicine and may withdraw from a telemedicine encounter at any time, without affecting your right to future treatment. You have the right to access your medical information and copies of medical records in accordance with federal and state law; however, should you decide to re-disclose this information to any other third party, it is no longer protected by HIPAA.
5. Risks. There are potential risks to using telemedicine technology, including interruptions, unauthorized access and technical difficulties. You or your mental health provider can discontinue the telemedicine consultation if it is felt that the telemedicine connections are not adequate for the situation. I agree to hold Bend Health harmless for delays in evaluation or for information lost due to technical failures as described above.If you need to receive follow-up care or assistance, please contact your Bend Health provider by emailing up at firstname.lastname@example.org In the event you are unable to communicate with your Bend Health provider due to a technological or equipment failure, please contact Bend Health at 1-800-516-0975.
If a member or patient needs emergency services, we recommend calling 9-1-1, Local Emergency Resources, National Suicide Hotline (1-800-273-8255) or crisis text line.
6. Text Messages. It may be useful during the course of treatment to communicate by email, text message, or other electronic methods of communication. These methods, in their typical form, are NOT a confidential, secure, means of communication. Communications over the internet, including email, and texting may not be encrypted or secure. There is no assurance of confidentiality when communications are made through these channels. There is a reasonable chance that a third party may be able to intercept these communications and your protected health information. Third parties that may be able to intercept and monitor these communications may include, but are not limited to:
7. Sharing Information. Bend Health may use and disclose your User Data and other health information as stated in our Notice of Privacy Practices. Bend Health uses Paubox secured email and other secured and compliant messaging technologies to store and transmit electronic communications with the client. Please note that, in accordance with applicable law and upon request, your primary care provider may obtain a copy of records regarding your telemedicine encounter with Bend Health. Your health care provider may also release information regarding the telehealth exam to Bend Health and its affiliates.
8. Website Owner-Operator. The owner of the telemedicine platform is Bend Health, Inc., 2801 Marshall Ct, Madison, WI 53705, and can be contacted at email@example.com
9. Revocation. You make revoke this authorization at any time by contacting us by email or mail and requesting revocation of this authorization.
* Bend Health Psychiatric Services South, P.C.
Bend Health Psychiatric Services South Central, P.A.
Bend Health Psychiatric Services Atlantic, P.C.
Bend Health Psychiatric Services Midwest, P.C.
Bend Health Psychiatric Services Kansas, P.A.
Psychiatric Telehealth Services, P.C.
Roots Psychiatric Services, P.C.
If your physician has indicated that a medication, including a controlled medication may assist in your symptomatic relief you agree to the following.Controlled medicine can be dangerous and habit forming. These medicines must be taken only as prescribed by your doctor. Please read this consent and agreement thoroughly and ask any questions you may have. If you are in agreement and fully understand the benefits and risks of the medications, sign and date below.
Bend Health Coaching Services
The Bend Health coaching service is not intended to provide medical services or advice and is not intended to be a substitute for the advice provided by your own physician or other medical professional. No part of the coaching service is intended to constitute professional advice for a medical diagnosis or medical treatment. Participation in the coaching service does not replace medical consultations with a qualified health or medical professional.
The coaching service is offered on a secure platform, and Bend Health follows Health Insurance Portability and Accountability Act (HIPAA) standards. By scheduling with a coach, you agree that you understand and will comply with the following:
When connecting to Bend Health, you may receive messages that contain Protected Health Information (PHI). We will attempt to send these messages in an encrypted manner but we cannot control the end-to-end encryption. You may still opt-in to receiving email and push notifications but this notice serves to inform you that we cannot control all access of delivery and your information may be exposed.
Last updated October 12, 2021
Thank you for choosing to be part of our community at Bend Health P.C. (“Company”, “we”, “us”, or “our”). We are committed to protecting your personal information and your right to privacy. If you have any questions or concerns about our policy, or our practices with regards to your personal information, please contact us at firstname.lastname@example.org.
1. WHAT INFORMATION DO WE COLLECT?
Personal information you disclose to us
In Short: We collect personal information that you provide to us such as name, address, contact information, passwords and security data, and depending on the services, payment information.
We collect personal information that you voluntarily provide to us when registering at the Services expressing an interest in obtaining information about us or our products and services, when participating in activities on the Services or Apps (such as posting messages in our online forums or entering competitions, contests or giveaways) or otherwise contacting us.
The personal information that we collect depends on the context of your interactions with us and the Services, the choices you make and the products and features you use. The personal information we collect can include the following:
Publicly Available Personal Information. We collect first name, maiden name, last name, nickname, ID, email addresses, phone numbers, and other similar data.
Personal Information Provided by You. We collect data about health, medical records, and similar apps, financial information (credit card number, purchase history, invoices), and other similar data.
Credentials. We collect passwords, password hints, and similar security information used for authentication and account access.
Payment Data. We collect data necessary to process your payment if you make purchases, such as your payment instrument number (such as a credit card number), and the security code associated with your payment instrument. All personal information that you provide to us must be true, complete and accurate, and you must notify us of any changes to such personal information.
Information automatically collected
In Short: Some information – such as IP address and/or browser and device characteristics – is collected automatically when you visit our Services or Apps.
We automatically collect certain information when you visit, use or navigate the Services. This information does not reveal your specific identity (like your name or contact information) but may include device and usage information, such as your IP address, browser and device characteristics, operating system, language preferences, referring URLs, device name, country, location, information about how and when you use our Services or Apps and other technical information. This information is primarily needed to maintain the security and operation of our Services or Apps, and for our internal analytics and reporting purposes.
Information collected through our Services
In Short: We may collect information regarding your geo-location, push notifications, when you use our apps.
If you use our Services, we may also collect the following information:
2. HOW DO WE USE YOUR INFORMATION?
In Short: We process your information for purposes based on legitimate business interests, the fulfillment of our contract with you, compliance with our legal obligations, and/or your consent.
We use personal information collected via our Services for a variety of business purposes described below. We process your personal information for these purposes in reliance on our legitimate business interests, in order to enter into or perform a contract with you, with your consent, and/or for compliance with our legal obligations. We indicate the specific processing grounds we rely on next to each purpose listed below.
We use the information we collect or receive:
To facilitate account creation and logon process. If you choose to link your account with us to a third-party account (such as your Google or Facebook account), we use the information you allowed us to collect from those third parties to facilitate account creation and logon process for the performance of the contract.
To send you marketing and promotional communications. We and/or our third-party marketing partners may use the personal information you send to us for our marketing purposes, if this is in accordance with your marketing preferences. You can opt-out of our marketing emails at any time (see the "WHAT ARE YOUR PRIVACY RIGHTS" below).
To send administrative information to you. We may use your personal information to send you product, service and new feature information and/or information about changes to our terms, conditions, and policies.
Fulfill and manage your orders. We may use your information to fulfill and manage your orders, payments, returns, and exchanges made through the Services or Apps.
To post testimonials. We post testimonials on our Services that may contain personal information. Prior to posting a testimonial, we will obtain your consent to use your name and testimonial. If you wish to update, or delete your testimonial, please contact us and be sure to include your name, testimonial location, and contact information.
Request Feedback. We may use your information to request feedback and to contact you about your use of our Services.
To enable user-to-user communications. We may use your information in order to enable user-to-user communications with each user's consent.
To enforce our terms, conditions and policies for Business Purposes, Legal Reasons and Contractual.
To respond to legal requests and prevent harm. If we receive a subpoena or other legal request, we may need to inspect the data we hold to determine how to respond.
To manage user accounts. We may use your information for the purposes of managing our account and keeping it in working order.
To deliver services to the user. We may use your information to provide you with the requested service.
To respond to user inquiries/offer support to users. We may use your information to respond to your inquiries and solve any potential issues you might have with the use of our Services.
For other Business Purposes. We may use your information for other Business Purposes, such as data analysis, identifying usage trends, determining the effectiveness of our promotional campaigns and to evaluate and improve our Services or Apps, products, marketing and your experience. We may use and store this information in aggregated and anonymized form so that it is not associated with individual end users and does not include personal information. We will not use identifiable personal information without your consent.
3. WILL YOUR INFORMATION BE SHARED WITH ANYONE?
In Short: We only share information with your consent, to comply with laws, to provide you with services, to protect your rights, or to fulfill business obligations.
We may process or share data based on the following legal basis:
Consent: We may process your data if you have given us specific consent to use your personal information in a specific purpose.
Legitimate Interests: We may process your data when it is reasonably necessary to achieve our legitimate business interests.
Performance of a Contract: Where we have entered into a contract with you, we may process your personal information to fulfill the terms of our contract.
Legal Obligations: We may disclose your information where we are legally required to do so in order to comply with applicable law, governmental requests, a judicial proceeding, court order, or legal process, such as in response to a court order or a subpoena (including in response to public authorities to meet national security or law enforcement requirements).
Vital Interests: We may disclose your information where we believe it is necessary to investigate, prevent, or take action regarding potential violations of our policies, suspected fraud, situations involving potential threats to the safety of any person and illegal activities, or as evidence in litigation in which we are involved.More specifically, we may need to process your data or share your personal information in the following situations:
Vendors, Consultants and Other Third-Party Service Providers. We may share your data with third party vendors, service providers, contractors or agents who perform services for us or on our behalf and require access to such information to do that work. Examples include: payment processing, data analysis, email delivery, hosting services, customer service and marketing efforts. We may allow selected third parties to use tracking technology on the Services, which will enable them to collect data about how you interact with the Services or Apps over time. This information may be used to, among other things, analyze and track data, determine the popularity of certain content and better understand online activity. Unless described in this Policy, we do not share, sell, rent or trade any of your information with third parties for their promotional purposes.
Business Transfers. We may share or transfer your information in connection with, or during negotiations of, any merger, sale of company assets, financing, or acquisition of all or a portion of our business to another company.
Third-Party Advertisers. We may use third-party advertising companies to serve ads when you visit the Services or Apps. These companies may use information about your visits to our Website(s) and other websites that are contained in web cookies and other tracking technologies in order to provide advertisements about goods and services of interest to you.
Other Users. When you share personal information (for example, by posting comments, contributions or other content to the Services or Apps) or otherwise interact with public areas of the Services or Apps, such personal information may be viewed by all users and may be publicly distributed outside the Services or Apps in perpetuity. Similarly, other users will be able to view descriptions of your activity, communicate with you within our Services or Apps, and view your profile.
4. HOW LONG DO WE KEEP YOUR INFORMATION?
5. HOW DO WE KEEP YOUR INFORMATION SAFE?
In Short: We aim to protect your personal information through a system of organizational and technical security measures.
We have implemented appropriate technical and organizational security measures designed to protect the security of any personal information we process. However, please also remember that we cannot guarantee that the internet itself is 100% secure. Although we will do our best to protect your personal information, transmission of personal information to and from our Services or Apps is at your own risk. You should only access the services within a secure environment.
6. DO WE COLLECT INFORMATION FROM MINORS?
In Short: We do not knowingly collect data from or market to children under 18 years of age.
By using the Services or Apps, you represent that you are at least 18 or that you are the parent or guardian of such a minor and consent to such minor dependent’s use of the Services or Apps. If we learn that personal information from users less than 18 years of age has been collected, we will take reasonable measures to promptly delete such data from our records. If you become aware of any data we have collected from children under age 18, please contact us (email@example.com).
7. WHAT ARE YOUR PRIVACY RIGHTS?
In Short: You may review, change, or terminate your account at any time.
If you are resident in the European Economic Area and you believe we are unlawfully processing your personal information, you also have the right to complain to your local data protection supervisory authority. You can find their contact details here: http://ec.europa.eu/justice/data-protection/bodies/authorities/index_en.htm.
Opting out of email marketing: You can unsubscribe from our marketing email list at any time by clicking on the unsubscribe link in the emails that we send or by contacting us using the details provided below. You will then be removed from the marketing email list – however, we will still need to send you service-related emails that are necessary for the administration and use of your account. To otherwise opt-out, you may: Contact us using the contact information provided (firstname.lastname@example.org).
8. CONTROLS FOR DO-NOT-TRACK FEATURES
9. DO CALIFORNIA RESIDENTS HAVE SPECIFIC PRIVACY RIGHTS?
In Short: Yes, if you are a resident of California, you are granted specific rights regarding access to your personal information.
California Civil Code Section 1798.83, also known as the “Shine The Light” law, permits our users who are California residents to request and obtain from us, once a year and free of charge, information about categories of personal information (if any) we disclosed to third parties for direct marketing purposes and the names and addresses of all third parties with which we shared personal information in the immediately preceding calendar year. If you are a California resident and would like to make such a request, please submit your request in writing to us using the contact information provided below.
If you are under 18 years of age, reside in California, and have a registered account with the Services or Apps, you have the right to request removal of unwanted data that you publicly post on the Services or Apps. To request removal of such data, please contact us using the contact information provided below, and include the email address associated with your account and a statement that you reside in California. We will make sure the data is not publicly displayed on the Services or Apps, but please be aware that the data may not be completely or comprehensively removed from our systems.
10. DO WE MAKE UPDATES TO THIS POLICY?
In Short: Yes, we will update this policy as necessary to stay compliant with relevant laws.
11. HOW CAN YOU CONTACT US ABOUT THIS POLICY?
If you have questions or comments about this policy, you may email us (email@example.com)..
HOW CAN YOU REVIEW, UPDATE, OR DELETE THE DATA WE COLLECT FROM YOU?
Based on the laws of some countries, you may have the right to request access to the personal information we collect from you, change that information, or delete it in some circumstances. To request to review, update, or delete your personal information, please submit a request form. We will respond to your request within 30 days.
You may not access or use the Site for any purpose other than that for which we make the Site available. The Site may not be used in connection with any commercial endeavors except those that are specifically endorsed or approved by us.As a user of the Site, you agree not to:
Bend Health Service Disclaimers
Money Back Guarantee (FOR SELF-PAY MEMBERS oNLY)
Bend Health provides a money-back guarantee to self-pay members only for its expert clinical services which promises clinically significant improvement over baseline.
Monthly Service renewal
Bend Health’s programs are set up to automatically renew monthly. For optimal treatment, new medications typically need to be monitored for at least 12 months.
TERM AND TERMINATION
If we terminate or suspend your account for any reason, you are prohibited from registering and creating a new account under your name, a fake or borrowed name, or the name of any third party, even if you may be acting on behalf of the third party. In addition to terminating or suspending your account, we reserve the right to take appropriate legal action, including without limitation pursuing civil, criminal, and injunctive redress.
MODIFICATIONS AND INTERRUPTIONSWe reserve the right to change, modify, or remove the contents of the Site at any time or for any reason at our sole discretion without notice. However, we have no obligation to update any information on our Site. We also reserve the right to modify or discontinue all or part of the Platform Offerings without notice at any time. We will not be liable to you or any third party for any modification, price change, suspension, or discontinuance of the Site or the Platform Offerings.
THE SITE AND THE PLATFORM OFFERINGS ARE PROVIDED ON AN AS-IS AND AS-AVAILABLE BASIS. YOU AGREE THAT YOUR USE OF THE SITE AND OUR SERVICES WILL BE AT YOUR SOLE RISK. TO THE FULLEST EXTENT PERMITTED BY LAW, WE DISCLAIM ALL WARRANTIES, EXPRESS OR IMPLIED, IN CONNECTION WITH THE SITE AND THE PLATFORM OFFERINGS AND YOUR USE THEREOF, INCLUDING, WITHOUT LIMITATION, THE IMPLIED WARRANTIES OF MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, AND NON-INFRINGEMENT. WE MAKE NO WARRANTIES OR REPRESENTATIONS ABOUT THE ACCURACY OR COMPLETENESS OF THE SITE’S CONTENT OR THE CONTENT OF ANY WEBSITES LINKED TO THE SITE AND WE WILL ASSUME NO LIABILITY OR RESPONSIBILITY FOR ANY (1) ERRORS, MISTAKES, OR INACCURACIES OF CONTENT AND MATERIALS, (2) PERSONAL INJURY OR PROPERTY DAMAGE, OF ANY NATURE WHATSOEVER, RESULTING FROM YOUR ACCESS TO AND USE OF THE SITE, (3) ANY UNAUTHORIZED ACCESS TO OR USE OF OUR SECURE SERVERS AND/OR ANY AND ALL PERSONAL INFORMATION AND/OR FINANCIAL INFORMATION STORED THEREIN, (4) ANY INTERRUPTION OR CESSATION OF TRANSMISSION TO OR FROM THE SITE OR THE PLATFORM OFFERINGS, (5) ANY BUGS, VIRUSES, TROJAN HORSES, OR THE LIKE WHICH MAY BE TRANSMITTED TO OR THROUGH THE SITE BY ANY THIRD PARTY, AND/OR (6) ANY ERRORS OR OMISSIONS IN ANY CONTENT AND MATERIALS OR FOR ANY LOSS OR DAMAGE OF ANY KIND INCURRED AS A RESULT OF THE USE OF ANY CONTENT POSTED, TRANSMITTED, OR OTHERWISE MADE AVAILABLE VIA THE SITE. WE DO NOT WARRANT, ENDORSE, GUARANTEE, OR ASSUME RESPONSIBILITY FOR ANY PRODUCT OR SERVICE ADVERTISED OR OFFERED BY A THIRD PARTY THROUGH THE SITE, ANY HYPERLINKED WEBSITE, OR ANY WEBSITE OR MOBILE APPLICATION FEATURED IN ANY BANNER OR OTHER ADVERTISING, AND WE WILL NOT BE A PARTY TO OR IN ANY WAY BE RESPONSIBLE FOR MONITORING ANY TRANSACTION BETWEEN YOU AND ANY THIRD-PARTY PROVIDERS OF PRODUCTS OR SERVICES. AS WITH THE PURCHASE OF A PRODUCT OR SERVICE THROUGH ANY MEDIUM OR IN ANY ENVIRONMENT, YOU SHOULD USE YOUR BEST JUDGMENT AND EXERCISE CAUTION WHERE APPROPRIATE.
LIMITATIONS OF LIABILITY
IN NO EVENT WILL WE OR OUR DIRECTORS, EMPLOYEES, OR AGENTS BE LIABLE TO YOU OR ANY THIRD PARTY FOR ANY DIRECT, INDIRECT, CONSEQUENTIAL, EXEMPLARY, INCIDENTAL, SPECIAL, OR PUNITIVE DAMAGES, INCLUDING LOST PROFIT, LOST REVENUE, LOSS OF DATA, OR OTHER DAMAGES ARISING FROM YOUR USE OF THE SITE OR THE PLATFORM OFFERINGS, EVEN IF WE HAVE BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGES. NOTWITHSTANDING ANYTHING TO THE CONTRARY CONTAINED HEREIN, OUR LIABILITY TO YOU FOR ANY CAUSE WHATSOEVER AND REGARDLESS OF THE FORM OF THE ACTION, WILL AT ALL TIMES BE LIMITED TO THE LESSER OF THE AMOUNT PAID, IF ANY, BY YOU TO US DURING THE SIX (6) MONTH PERIOD PRIOR TO ANY CAUSE OF ACTION ARISING OR. CERTAIN US STATE LAWS AND INTERNATIONAL LAWS DO NOT ALLOW LIMITATIONS ON IMPLIED WARRANTIES OR THE EXCLUSION OR LIMITATION OF CERTAIN DAMAGES. IF THESE LAWS APPLY TO YOU, SOME OR ALL OF THE ABOVE DISCLAIMERS OR LIMITATIONS MAY NOT APPLY TO YOU, AND YOU MAY HAVE ADDITIONAL RIGHTS.
Any controversy or claim arising out of or relating to this contract, or the breach thereof, shall be settled by arbitration administered in Madison, Wisconsin under its [Commercial Arbitration Rules/Healthcare Payor Provider Rules/Rules of Procedure for Arbitration by the American Health Lawyers Association]. The number of arbitrators shall be one. The place of arbitration shall be located in the state of Delaware. Delaware law shall apply. Judgment on the award rendered by the arbitrator(s) may be entered in any court having jurisdiction thereof. The costs of arbitration will be split evenly between the Clinician and BEND HEALTH.