Telehealth Informed
Consent

I hereby give my consent to examination and treatment by Anora Health's medical staff, including diagnostic services, medications, laboratory procedures or other medically necessary services. I acknowledge and consent that the evaluation, treatment, and care I receive at Anora Health will be provided by the Nurse Practitioners, physicians, Doctor of Osteopathic Medicine, or Physician assistants. I understand that services may include, but are not limited to, medical evaluation, psychological assessments, counseling, psychotherapy, medication management, and other therapeutic interventions as deemed necessary.

Understanding of Services:

I understand that medical evaluations need to be accurate and that I will provide accurate information to guide decision making process and that the provider will exercise judgement in providing accurate evaluation and diagnosis.

I understand that mental health treatment may involve discussing sensitive issues, which can sometimes lead to emotional discomfort.

I acknowledge that the clinician will provide information regarding the proposed treatment, potential risks and benefits, alternative options, and the expected outcomes. I understand that I have the right to ask questions and receive satisfactory answers regarding my treatment plan.

I understand and I am informed that, as with all healthcare treatments, results are not guaranteed and there is no promise of cure.

I have had the opportunity to discuss with my provider the nature and purpose of treatments and procedures. I am aware that all existing methods of diagnosis and treatment pose some level of risk.

I do not expect the provider to be able to anticipate and explain all risks and complications, and I wish to rely on the provider to exercise judgment during the course of the treatment which the provider feels at the time, based upon the facts then known, is in my best interests.

I will immediately inform the provider if I experience any unanticipated or unpleasant effects associated with treatment prescribed/recommended. I understand that if an emergency medical condition arises, I am expected to call 9-1-1.

I understand and provide my informed consent to receive psychotherapy services at Anora. I understand the following:

• Nature of Services: Psychotherapy involves discussing personal issues, which may cause emotional discomfort, but it is intended to improve mental health and well-being.
• Confidentiality: All information shared is confidential, except as required by law — for example, threats of harm to self or others, or as mandated for child/elder abuse reporting.
• Voluntary Participation: Participation in therapy is voluntary, and I may withdraw consent or discontinue treatment at any time.
• Limits & Risks: No guarantee of specific outcomes is given. Potential benefits and risks have been explained to me.
• Legal Acknowledgment: I have read and understood this consent, had the opportunity to ask questions, and agree to receive mental health services.

Purpose of Coaching

Coaching is a collaborative process designed to support personal growth, skill development, and the achievement of client-identified goals. Our coaching may include strategies for organization, time management, focus, and self-advocacy.

Nature of Coaching

Coaching is not psychotherapy, medical treatment, or a substitute for mental health or medical care. Coaches do not diagnose, treat, or prescribe for physical or mental health conditions. Clients are encouraged to continue any medical or therapeutic treatments as prescribed by healthcare professionals.

Confidentiality

All information shared in sessions is kept confidential, except as required by law (e.g., risk of harm to self or others, court order, or mandatory reporting).

Client Responsibilities

Clients are expected to actively participate, set personal goals, and communicate openly with their coach. Progress depends on the client's engagement and effort.

Risks and Benefits

While coaching often leads to improved skills and insight, results are not guaranteed. Clients may experience temporary discomfort when facing challenges or making changes.

Consent

I acknowledge that I have read and understood this informed consent, and I voluntarily consent to participate in coaching services at Anora.

The session content and all relevant materials to the client's treatment will be held confidential between client and staff of ANORA Health unless the client requests in writing to have all or portions of such content released to a specifically named person/persons. Limitations of such client held privilege of confidentiality exist and are itemized below:

• If a client threatens or attempts to commit suicide or otherwise conducts him/her self in a manner in which there is a substantial risk of incurring serious bodily harm.
• If a client threatens grave bodily harm or death to another person.
• If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years.
• Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.
• Suspected neglect of the parties named in the items above.
• If a court of law issues a legitimate subpoena for information stated on the subpoena.
• If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert's report to an attorney.

Occasionally I may need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information about you may be shared in this context without using your name.

If we see each other accidentally outside of the therapy office, we will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to us, and we do not wish to jeopardize your privacy. However, if you acknowledge us first, we will be more than happy to speak briefly with you, but feel it appropriate not to engage in any lengthy discussions in public or outside of treatment.

I consent to voluntarily engage in a telemedicine consultation with the practice. I understand that the video conferencing technology will not be the same as a direct patient/health care provider visit:

Telehealth consultation has potential benefits, including easier access to care, decreasing costs, and allowing visits to be performed from the comfort of my home. It also has potential risks including interruptions, unauthorized access, and technical difficulties.

I understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.

If there is another individual present during the telehealth consultation, I will be informed of their presence and I will also disclose if there is another individual with myself. It is agreed that these individuals will maintain confidentiality of the information obtained. 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/physical examination that are personally sensitive to me; (2) ask non-medical personnel to leave the telemedicine examination room; and or (3) terminate the consultation at any time.

I understand that telemedicine has limitations in regard to the physical examination. I understand that the physical exam portion of the care provided through the practice will be limited to inspection via video conferencing and some parts of the exam such as physical tests, examination of certain body parts, and vital signs may be conducted by individuals at my location at the direction of the consulting health care provider or not done at all.

TELEMEDICINE SERVICES OFFERED THROUGH THE PRACTICE ARE NOT AN EMERGENCY SERVICE AND IN THE EVENT OF AN EMERGENCY OR URGENT MEDICAL ISSUE, I WILL USE A PHONE TO CALL 911, GO TO THE EMERGENCY DEPARTMENT, OR GO TO AN URGENT CARE. IF I AM HAVING A MENTAL HEALTH CRISIS, I WILL CALL OR TEXT 988.

To maintain my privacy, I will not share telemedicine login information or video conferencing links with anyone unauthorized to attend the appointment.

This consent form acknowledges your understanding and agreement to the use of technology designed to create medical notes from conversations between caregivers and patients during medical consultations and appointments. The technology will securely capture and transcribe verbal interactions to assist in accurate documentation of your medical information. This enhances the quality of your healthcare records and supports your treatment. All recorded data will be handled with strict confidentiality, in compliance with applicable healthcare privacy laws. The information will be used solely for the purpose of maintaining accurate medical records and will not be shared without your explicit consent, unless required by law. Your participation is voluntary. You may withdraw your consent at any time without affecting the quality of care you receive. If you choose not to consent, traditional methods of note-taking will be used instead.

I understand that the practitioner / the practice may, on rare occasions, allow telephone consultations — verbal conversation only / no video. I understand that these consultations have considerable limitations, including but not limited to no physical exam or visual assessment. I understand that my provider, during the telephone consultation, may determine that adequate care and treatment will not be possible with the limited assessment via telephone consultation. I agree to follow through with them on any required in-person office visits or video tele-health visits. I consent to receive instructions via phone/telemedicine platform and take full responsibility to follow through with specific instructions as required for my treatment. I have had the opportunity to discuss the limitations with my provider.

The preferred method of communication is via HIPAA-compliant Patient Portal. However, the practitioner / the practice provides patients with the opportunity to communicate by e-mail. Transmitting confidential health information by e-mail, however, has a number of risks: E-mail can be immediately broadcast worldwide and be received by many intended and unintended recipients; recipients can forward e-mail messages to other recipients without the original sender(s) permission or knowledge; users can easily copy information.

It is the policy of the practitioner / practice that all e-mail messages sent or received which concern the diagnosis or treatment of a patient will be a part of the patient's protected personal health information. The practice cannot guarantee the security and confidentiality of e-mail or internet communication.

Patients may consent to the use of e-mail for confidential medical information after having been informed of the above risks with the following conditions: All e-mails to or from patients concerning diagnosis and/or treatment will be made part of the protected personal health information. As a part of the protected personal health information, other individuals, insurance coordinators and, upon written authorization, other healthcare providers and insurers will have access to e-mail messages contained in protected personal health information.

The practitioner / practice will endeavor to read e-mail promptly. However, the practice can provide no assurance that the e-mail will be read immediately. Therefore, e-mail must never be used in a medical emergency.

Because some medical information is so sensitive that unauthorized disclosure can be damaging, e-mail should not be used for communications concerning diagnosis or treatment of any sexually transmittable or communicable diseases such as syphilis, gonorrhea, and the like; behavioral health, mental health; or alcohol and drug abuse.

The practitioner / practice cannot guarantee that electronic communications will be private. The practitioner / practice is not liable for improper disclosure of confidential information not caused by its employee's gross negligence or wanton misconduct and is not liable for breaches of confidentiality caused by the patient.

I understand that my consent to the use of e-mail may be withdrawn at any time, whether it be by e-mail or written communication to the practitioner / practice. I have read this form carefully and understand the risks and responsibility associated with the use of e-mail. I agree to assume all risks associated with the use of e-mail.

The practitioner / practice may need to use my name, address, phone number, and my clinical records to contact me with appointment reminders/text message, information about treatment alternatives or other health related information that may be of interest to me. If this contact is made by phone and I am not available, a message will be left on my answering machine or with the person answering the phone.

Message and data rates may apply and message frequency may vary. You can contact the practice at any point to request that your mobile number not be used for messaging. You can text HELP for support or more information and STOP to unsubscribe from text messages at any time. If you unsubscribe, you will no longer get appointment reminder messages. Your phone number will not be shared with third parties for marketing or promotional purposes.

I am giving the practice the authorization to contact me with these reminders and information and to leave a message on my answering machine or with individuals at my home or place of employment.