This Informed Consent for Telehealth contains important information focusing on providing healthcare services using the phone or the Internet. Please read this carefully, and let a staff member know if you have any questions. When you sign this document, it will represent an agreement between you and Providers at Mojo Men's Health Inc.

Benefits and Risks of Telehealth

Telehealth refers to providing healthcare services remotely using telecommunications technologies, such as video conferencing or telephone. One of the benefits of telehealth is that the patient and clinician can engage in services without being in the same physical location. This can be helpful particularly helpful in ensuring continuity of care as the patient and clinician likely are in different locations or are otherwise unable to continue to meet in person. It is also more convenient and takes less time. Telehealth, however, requires technical competence on both our parts to be helpful. Although there are benefits of telehealth, there are some differences between in-person treatment and telehealth, as well as some risks. For example:

Risks to Confidentiality. As telehealth sessions take place outside of the office setting, there is potential for other people to overhear sessions if you are not in a private place during the session. Mojo Men's Health Inc. will take reasonable steps to ensure your privacy. It is important; however, for you to make sure you find a private place for our session where you will not be interrupted. It is also important for you to protect the privacy of our session on your cell phone or other device. You should participate in therapy only while in a room or area where other people are not present and cannot overhear the conversation.

Issues related to Technology. There are many ways that technology issues might impact telehealth. For example, technology may stop working during a session, other people might be able to get access to our private conversation, or stored data could be accessed by unauthorized people or companies.

Crisis Management and Intervention. Usually, your provider at Mojo Men's Health Inc. will not engage in telehealth with clients who are currently in a crisis situation requiring high levels of support and intervention. We may not have an option of in-person services presently, but in a crisis situation, you may require a higher level of services. Before engaging in telehealth, we will develop an emergency response plan to address potential crisis situations that may arise during the course of our telehealth work.

Electronic Communications

You may have to have certain computer or cell phone systems to use telehealth services. You are solely responsible for any cost to you to obtain any necessary equipment, accessories, or software to take part in telehealth.

For communication between sessions, Mojo Men's Health Inc. utilizes an in-house chat feature that complies with HIPAA and other applicable federal medical privacy regulations with your permission and only for administrative purposes unless we have made another agreement. You should be aware that Mojo Men's Health Inc. cannot guarantee the confidentiality of any information communicated by email or text. Therefore, any clinical information by email or text will not be discussed, and we prefer that you do not either. Also, Providers at Mojo Men's Health Inc do not regularly check patient portal messages, and do not respond immediately, therefore, these methods should not be used if there is an emergency.

A staff member will attempt to return your call within 24 hours except on weekends and holidays. If you are unable to reach a staff member and feel that you cannot wait for a return call, and if you need immediate attention, contact the nearest emergency room. If Provider will be unavailable for an extended time, you will be notified via patient portal message.

Confidentiality

Providers at Mojo Men's Health Inc have a legal and ethical responsibility to make best efforts to protect all communications that are a part of telehealth services. The nature of electronic communications technologies, however, is such that it cannot be guaranteed that patient/ provider communications will be kept confidential or that other people may not gain access to our communications. Mojo Men's Health Inc will try to use updated encryption methods, firewalls, and back-up systems to help keep your information private, but there is a risk that our electronic communications may be compromised, unsecured, or accessed by others. You should also take reasonable steps to ensure the security of our communications (for example, only using secure networks for telehealth sessions and having passwords to protect the device you use for telehealth).

The extent of confidentiality and the exceptions to confidentiality that have been outlined in this Informed Consent still apply in telehealth. Please let a staff member know if you have any questions about exceptions to confidentiality.

Appropriateness of Telehealth

During this time, it may not be possible to engage in in-person sessions to "check-in" with one another. Your Provider at Mojo Men's Health Inc will let you know if it is decided that telehealth is no longer the most appropriate form of treatment for you. If you decide telehealth is not optimal for you, it is important to let you Provider know. We will discuss options of engaging in referrals to another professional in your location who can provide appropriate services.

Emergencies and Technology

Assessing and evaluating threats and other emergencies can be more difficult when conducting telehealth than in traditional in-person treatment. To address some of these difficulties, we will create an emergency plan before engaging in telehealth services. You will be asked you to identify an emergency contact person who is near your location and who will be contacted in the event of a crisis or emergency to assist in addressing the situation. You will be asked to sign a separate authorization form allowing your Provider to contact your emergency contact person as needed during such a crisis or emergency.

If the session is interrupted for any reason, such as technological connection failure, and you are having an emergency, do not call your Provider back; instead, call 9-1-1 immediately, or go to your nearest emergency room if safe to do so. A call can be placed back to your Provider after you have called or obtained emergency services.

If the session is interrupted and you are not having an emergency, disconnect from the session and your Provider will wait two (2) minutes and then re-connect you via the telehealth platform on which we agreed to conduct treatment.

Records

The telehealth sessions shall not be recorded in any way unless agreed to in writing by mutual consent. A photograph of you may be captured during your visit to attached to your telehealth visit summary as documentation of your presence during the telehealth visit for submission to insurance and/or for your medical record. Your telehealth session record will be maintained in the same way records of in-person sessions in accordance with Mojo Men's Health Inc. policies.

Informed Consent

This agreement is intended as informed consent.