This form describes Spring Health’s treatment and payment policies for children under 18 and includes:Your consent on behalf of the patient to receive mental health treatment from Spring Health or a Spring Health affiliated provider;Your agreement on behalf of the minor patient to receive services using telehealth technology, as applicable; andYour agreement to pay in full any charges that are your responsibility You represent that you are the patient’s parent or legal guardian and are duly authorized under state law to act on behalf of the minor. All references to “you” or “I” shall be deemed to include the minor patient where such reference applies to the individual receiving care.

By typing your name and clicking “I agree to the Terms of Service” on the Spring Health website, you agree on behalf of the minor patient:

1. I understand that the laws that protect the privacy and the confidentiality of medical information also apply to telemedicine and that no information obtained in the use of telemedicine which identifies me will be disclosed to other non-covered entities without my consent.
2. I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.
3. Subject to applicable law, I understand that I have the right to inspect medical information obtained and recorded in the course of a provider visit, and may receive copies of this information for a reasonable fee.
4. I understand that 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.
5. I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.
6. I understand that I may need to provide photo-identification and my physical location to allow for accurate and effective care to be delivered.
7. I understand that if I am having a medical emergency that I should immediately contact my personal physician, local emergency notification system, or go to the nearest emergency room.
8. I understand that it is my duty to inform my provider of interactions regarding my care that I may have with other healthcare providers.
9. I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.
10. I have read and understand the information provided below, have discussed it with my provider or such assistants as may be designated, and all of my questions have been answered to my satisfaction.
11. I hereby give my informed consent for the care outlined below and, if applicable, the use of telemedicine in my medical care.
12. I have read and understand the General Terms and Conditions below and agree to the policies outlined in this document.

General Terms and Conditions

Our services may include, without limitation, psychotherapy and medication management and may be performed using telehealth as a treatment modality. For some people, in-person psychotherapy and medication management may be available. Providers may include primary care practitioners, masters-level and doctoral-level therapists, psychiatrists or other specialists.

Psychotherapy

Often called talk therapy, this form of treatment can be helpful to individuals. Benefits can include improved mood, improved relationships, and resolution of specific problems. However, therapy is not guaranteed to work for everybody. Psychotherapy may also require exploring unpleasant aspects of your life and can, at times, lead to feelings of distress (i.e., guilt, anxiety, frustration, etc.) or a temporary increase in symptoms. These unpleasant aspects are generally temporary but are important to discuss when present. Thus, it is important to let your therapist know if you feel that your goals aren’t being met. These issues can be addressed in sessions, which typically last 50 minutes. Occasionally, therapists need to discontinue therapy. Although this is rare, if therapy ends prematurely, a suitable referral or transition will be discussed with you.

Medication Management

Medications may be indicated when your symptoms are not responsive to psychotherapy alone. When a mental illness markedly impacts your ability to work, maintain interpersonal relationships, or properly care for your basic needs, medication may offer much-needed relief. Not everyone is a good candidate for medication treatment. Such treatment requires adherence to prescribed dosing frequency and close follow-up. Your ability to adhere to medication treatment will be taken into consideration in making the decision to start such treatment. Additionally, your physician will discuss the risks, benefits, side effects, government warnings, and alternative treatments (which always includes not using medications) with you to help you determine the best treatment options available for your specific needs. Current federal law does not allow tele-providers to prescribe controlled substances without an in-person visit. If your tele-provider determines you need this type of medication, you may be referred to your primary care provider with a recommendation to prescribe this medication

Limitations to Evaluation Types

Spring providers are not able to provide the following types of evaluations: a return to work fitness for duty evaluations, parental custody evaluations, court-mandated treatment, emotional support animal evaluations, weapons purchase clearance evaluations or other similar administrative evaluations. Patients may request a copy of their patient record or ask for a statement letter for attendance at sessions. This information will be sent directly to patients. Patients can share these records directly with any agency of their choice. Spring and associated providers will not send patient records directly to any third party that is not involved in your patient care.

Consent to In-Person Care

If in-person psychotherapy or medication management services are available to you, and you chose to engage in those services, you certify that a provider has explained the nature, benefits, and potential risks of those services, and that you have been given the opportunity to ask questions about any concerns regarding the services.

Telehealth as a Treatment Modality

Telehealth involves the use of audio, video and other electronic communications to enable health care providers to access individual patient medical information for the purpose of patient care. As part of this process, your provider may need to verify your identity as well as ask your location during a session to provide effective care. Details of your medical history and personal health information may be discussed with you or other health care professionals through the use of interactive video, audio, or other telecommunications technology. Some patients do not find distance counseling to be as intimate or helpful as traditional in-person counseling. Often times, this is because it is a new way of communicating. However, once patients have participated in a couple of sessions they find that they can benefit from using telehealth. If you decide telehealth is not for you, you should promptly notify your therapist or Spring Care Navigator so an alternative, more effective mode of treatment may be arranged (by Spring and/or a third-party provider).

Expected Benefits of Telehealth:

• Improved access to medical care by enabling a patient to obtain consultations from a wider range of healthcare practitioners at distant/other sites that are not available for in-person care
• More efficient medical evaluation and management with a wider range of appointment availability compared to only in-person care
• More convenient care scheduling and logistics

Possible Risks of Telehealth:

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

• In rare cases, information transmitted may not be sufficient (e.g. poor connectivity) to allow for appropriate medical decision making by care providers;
• Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment;
• In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information;
• In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors;
• In some cases, it may be difficult for providers to track your location and guide your care in emergency situations;
• In some cases, you may have multiple individuals involved with your care to determine the ideal plan of treatment; these individuals may be psychotherapists, physicians, medical administrators, and care navigator staff.

Electronic Information/Systems:

Electronic information collected during your sessions may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:

• Patient medical records and electronic/paper communications
• Live two-way audio and video
• Output data from sound and video files
• Messaging appointment reminders to your phone

Electronic systems used in your care 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.

Personal Health Information Data Management:

Spring follows all applicable HIPAA federal guidelines in protecting and managing your data. Under HIPAA, you have a right to get a copy of your medical record, correct your medical record, ask us to limit the information we share, receive a list of those with whom we have shared your information, get a copy of this privacy notice, choose some to act for you and file a complaint if you believe your privacy rights have been violated

Under HIPAA, Spring is allowed to share your data without your consent with business associates with an HIPAA agreement in place for the following reasons: to facilitate your treatment; run our organization; bill for your services; help with public health and safety issues; do research; comply with other laws; address workers compensation, law enforcement, and other government requests; and respond to lawsuits and legal actions.

For more information on management of your protected health information contact your care navigator.

Patient Responsibility/Missed Appointment Policy:

• Spring is not an enrolled Medicaid or Medicare provider. If Spring does not participate in your health care plan, you may be responsible for greater out-of-pocket expenses than you would for an in-network service. You may submit a request for an estimate of the amount that you will be billed for the out-of-network service. Please submit your request to https://www.springhealth.com/support

• All out-of-network costs (OON) and self-pay members are required to pay the full session price on the day of session. Invoices will be delivered via email. At the end of each month, you will receive a superbill to reflect all services rendered and payments made. You can then independently submit the superbill to your insurance or coinsurance carrier for any possible reimbursements under your insurance plan.
• If Spring participates in your health care plan, you will be required to pay the in-network deductible or co-pay, according to your plan, within 24 hrs of the service rendered. Invoices will be delivered via email.
• If your employer offers a number of no cost visits per calendar year, you will be responsible for payment for any additional visits beyond those no cost offerings. Your insurance may cover a portion of those costs, as noted in the in-network and out-of-network notes above.
• Any outstanding balance is subject to a finance charge of 3% after 60 days past due.
• I understand all appointments have to be confirmed by me in advance to retain my time slot.
• If I cancel a visit within 24 hours of a scheduled telehealth visit, then I am responsible for a cancellation processing fee of $50 (or I will have an employer-sponsored visit deducted).
• If I am over 10 mins late to a telehealth therapy visit, it is up to the provider’s discretion to cancel or shorten a visit. If canceled, then I may be responsible for a cancellation fee as above.

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This form describes Spring Health’s treatment and payment policies for children under 18 and includes:Your consent on behalf of the patient to receive mental health treatment from Spring Health or a Spring Health affiliated provider;Your agreement on behalf of the minor patient to receive services using telehealth technology, as applicable; andYour agreement to pay in full any charges that are your responsibility You represent that you are the patient’s parent or legal guardian and are duly authorized under state law to act on behalf of the minor. All references to “you” or “I” shall be deemed to include the minor patient where such reference applies to the individual receiving care.

By typing your name and clicking “I agree to the Terms of Service” on the Spring Health website, you agree on behalf of the minor patient:

1. I understand that the laws that protect the privacy and the confidentiality of medical information also apply to telemedicine and that no information obtained in the use of telemedicine which identifies me will be disclosed to other non-covered entities without my consent.
2. I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.
3. Subject to applicable law, I understand that I have the right to inspect medical information obtained and recorded in the course of a provider visit, and may receive copies of this information for a reasonable fee.
4. I understand that 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.
5. I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.
6. I understand that I may need to provide photo-identification and my physical location to allow for accurate and effective care to be delivered.
7. I understand that if I am having a medical emergency that I should immediately contact my personal physician, local emergency notification system, or go to the nearest emergency room.
8. I understand that it is my duty to inform my provider of interactions regarding my care that I may have with other healthcare providers.
9. I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.
10. I have read and understand the information provided below, have discussed it with my provider or such assistants as may be designated, and all of my questions have been answered to my satisfaction.
11. I hereby give my informed consent for the care outlined below and, if applicable, the use of telemedicine in my medical care.
12. I have read and understand the General Terms and Conditions below and agree to the policies outlined in this document.

General Terms and Conditions

Our services may include, without limitation, psychotherapy and medication management and may be performed using telehealth as a treatment modality. For some people, in-person psychotherapy and medication management may be available. Providers may include primary care practitioners, masters-level and doctoral-level therapists, psychiatrists or other specialists.

Psychotherapy

Often called talk therapy, this form of treatment can be helpful to individuals. Benefits can include improved mood, improved relationships, and resolution of specific problems. However, therapy is not guaranteed to work for everybody. Psychotherapy may also require exploring unpleasant aspects of your life and can, at times, lead to feelings of distress (i.e., guilt, anxiety, frustration, etc.) or a temporary increase in symptoms. These unpleasant aspects are generally temporary but are important to discuss when present. Thus, it is important to let your therapist know if you feel that your goals aren’t being met. These issues can be addressed in sessions, which typically last 50 minutes. Occasionally, therapists need to discontinue therapy. Although this is rare, if therapy ends prematurely, a suitable referral or transition will be discussed with you.

Medication Management

Medications may be indicated when your symptoms are not responsive to psychotherapy alone. When a mental illness markedly impacts your ability to work, maintain interpersonal relationships, or properly care for your basic needs, medication may offer much-needed relief. Not everyone is a good candidate for medication treatment. Such treatment requires adherence to prescribed dosing frequency and close follow-up. Your ability to adhere to medication treatment will be taken into consideration in making the decision to start such treatment. Additionally, your physician will discuss the risks, benefits, side effects, government warnings, and alternative treatments (which always includes not using medications) with you to help you determine the best treatment options available for your specific needs. Current federal law does not allow tele-providers to prescribe controlled substances without an in-person visit. If your tele-provider determines you need this type of medication, you may be referred to your primary care provider with a recommendation to prescribe this medication

Limitations to Evaluation Types

Spring providers are not able to provide the following types of evaluations: a return to work fitness for duty evaluations, parental custody evaluations, court-mandated treatment, emotional support animal evaluations, weapons purchase clearance evaluations or other similar administrative evaluations. Patients may request a copy of their patient record or ask for a statement letter for attendance at sessions. This information will be sent directly to patients. Patients can share these records directly with any agency of their choice. Spring and associated providers will not send patient records directly to any third party that is not involved in your patient care.

Consent to In-Person Care

If in-person psychotherapy or medication management services are available to you, and you chose to engage in those services, you certify that a provider has explained the nature, benefits, and potential risks of those services, and that you have been given the opportunity to ask questions about any concerns regarding the services.

Telehealth as a Treatment Modality

Telehealth involves the use of audio, video and other electronic communications to enable health care providers to access individual patient medical information for the purpose of patient care. As part of this process, your provider may need to verify your identity as well as ask your location during a session to provide effective care. Details of your medical history and personal health information may be discussed with you or other health care professionals through the use of interactive video, audio, or other telecommunications technology. Some patients do not find distance counseling to be as intimate or helpful as traditional in-person counseling. Often times, this is because it is a new way of communicating. However, once patients have participated in a couple of sessions they find that they can benefit from using telehealth. If you decide telehealth is not for you, you should promptly notify your therapist or Spring Care Navigator so an alternative, more effective mode of treatment may be arranged (by Spring and/or a third-party provider).

Expected Benefits of Telehealth:

• Improved access to medical care by enabling a patient to obtain consultations from a wider range of healthcare practitioners at distant/other sites that are not available for in-person care
• More efficient medical evaluation and management with a wider range of appointment availability compared to only in-person care
• More convenient care scheduling and logistics

Possible Risks of Telehealth:

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

• In rare cases, information transmitted may not be sufficient (e.g. poor connectivity) to allow for appropriate medical decision making by care providers;
• Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment;
• In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information;
• In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors;
• In some cases, it may be difficult for providers to track your location and guide your care in emergency situations;
• In some cases, you may have multiple individuals involved with your care to determine the ideal plan of treatment; these individuals may be psychotherapists, physicians, medical administrators, and care navigator staff.

Electronic Information/Systems:

Electronic information collected during your sessions may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:

• Patient medical records and electronic/paper communications
• Live two-way audio and video
• Output data from sound and video files
• Messaging appointment reminders to your phone

Electronic systems used in your care 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.

Personal Health Information Data Management:

Spring follows all applicable HIPAA federal guidelines in protecting and managing your data. Under HIPAA, you have a right to get a copy of your medical record, correct your medical record, ask us to limit the information we share, receive a list of those with whom we have shared your information, get a copy of this privacy notice, choose some to act for you and file a complaint if you believe your privacy rights have been violated

Under HIPAA, Spring is allowed to share your data without your consent with business associates with an HIPAA agreement in place for the following reasons: to facilitate your treatment; run our organization; bill for your services; help with public health and safety issues; do research; comply with other laws; address workers compensation, law enforcement, and other government requests; and respond to lawsuits and legal actions.

For more information on management of your protected health information contact your care navigator.

Patient Responsibility/Missed Appointment Policy:

• Spring is not an enrolled Medicaid or Medicare provider. If Spring does not participate in your health care plan, you may be responsible for greater out-of-pocket expenses than you would for an in-network service. You may submit a request for an estimate of the amount that you will be billed for the out-of-network service. Please submit your request to https://www.springhealth.com/support

• All out-of-network costs (OON) and self-pay members are required to pay the full session price on the day of session. Invoices will be delivered via email. At the end of each month, you will receive a superbill to reflect all services rendered and payments made. You can then independently submit the superbill to your insurance or coinsurance carrier for any possible reimbursements under your insurance plan.
• If Spring participates in your health care plan, you will be required to pay the in-network deductible or co-pay, according to your plan, within 24 hrs of the service rendered. Invoices will be delivered via email.
• If your employer offers a number of no cost visits per calendar year, you will be responsible for payment for any additional visits beyond those no cost offerings. Your insurance may cover a portion of those costs, as noted in the in-network and out-of-network notes above.
• Any outstanding balance is subject to a finance charge of 3% after 60 days past due.
• I understand all appointments have to be confirmed by me in advance to retain my time slot.
• If I cancel a visit within 24 hours of a scheduled telehealth visit, then I am responsible for a cancellation processing fee of $50 (or I will have an employer-sponsored visit deducted).
• If I am over 10 mins late to a telehealth therapy visit, it is up to the provider’s discretion to cancel or shorten a visit. If canceled, then I may be responsible for a cancellation fee as above.

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ZUSTIMMUNG ZUM ERHALT VON DIENSTEN

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In diesem Formular sind die Richtlinien im Zusammenhang mit Beratungen und Sitzungen von Spring Health dargelegt, wobei folgende Punkte abgedeckt werden:

Ihre Zustimmung zum Erhalt von Beratungen von einem/einer mit Spring Health verbundenen Anbieter/in

Ihre Zustimmung zum Erhalt von Diensten mithilfe von Telemedizin-Technologie

Indem Sie „Ich stimme den Bedingungen der ‚Zustimmung zum Erhalt von Diensten‘ von Spring Health zu“ ankreuzen, erklären Sie, Folgendes gelesen und verstanden zu haben:

1. Mir ist bewusst, dass mir das Recht zusteht, meine Einwilligung zur Nutzung von Telegesundheitsdiensten im Rahmen meiner Behandlung jederzeit zu verweigern oder zu widerrufen.
2. Ich habe verstanden, dass mir eventuell eine Vielzahl alternativer Behandlungsmethoden zur Verfügung steht.
3. Weiterhin ist mir bekannt, dass ich im Falle eines medizinischen Notfalls sofort meinen Hausarzt, das örtliche Notfallmeldesystem oder die nächste Notaufnahme kontaktieren sollte.
4. Ich habe verstanden, dass es meine Pflicht ist, meinen Arzt über etwaige Interaktionen mit meinen Gesundheitsanbietern/-anbieterinnen im Zusammenhang mit meiner Behandlung zu informieren, soweit diese relevant sind. 
5. Die untenstehenden Informationen habe ich gelesen und verstanden.
6. Ich habe die Bedingungen der Haftungsbestimmungen für Spring Health-„Mitglieder“ sowie die Richtlinien für verpasste Termine gelesen und stimme den hierin aufgeführten Richtlinien zu.

GESUNDHEITSDIENSTE VON SPRING HEALTH UND DAMIT VERBUNDENE RICHTLINIEN

Unsere Dienstleistungen werden unter Umständen mithilfe von Telemedizin als Behandlungsmodalität erbracht. Diese Leistungen werden von Therapeuten und Therapeutinnen erbracht, die nicht zu Spring Health gehören. Dazu zählen Fachkräfte wie etwa Psychologen und Psychologinnen, Berater(innen) oder andere Spezialfachkräfte mit Qualifikationen bzw. Eintragungen bei den zuständigen Berufsverbänden, die für die Erbringung der entsprechenden Leistungen in Ihrem Land, Staat oder Ort erforderlich sind.

Spring Health bietet selbst keinerlei medizinische bzw. gesundheitliche Dienstleistungen oder Behandlungen an. Dieses Dokument ist ausschließlich für Informationszwecke bestimmt und darf nicht als medizinischer Rat aufgefasst werden. 

Grenzen der verschiedenen Beurteilungsarten

Anbieter/innen von Spring Health ist es nicht möglich, die folgenden Arten von Beurteilungen vorzunehmen: Medikamentenmanagement, Beurteilungen der Wiedereingliederung in den Beruf, Beurteilungen der elterlichen Sorge, gerichtlich angeordnete Behandlungen, Untersuchungen von Tieren zur emotionalen Unterstützung oder andere ähnliche behördliche Beurteilungen. Unsere Mitglieder können eine Kopie ihres Mitgliederdatensatzes oder eine Erklärung über die Teilnahme an den Sitzungen anfordern.  Es ist den Mitgliedern gestattet, diese Aufzeichnungen direkt an jede beliebige Agentur ihrer Wahl weiterzuleiten. Die Anbieter/innen werden Ihre Unterlagen nicht direkt an Dritte weiterleiten, die nicht an Ihrer Behandlung beteiligt sind, es sei denn, Sie haben ihnen eine schriftliche Genehmigung dazu erteilt.

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Telemedizin als Behandlungsmethode

Unter Telemedizin versteht man die Verwendung von Audio-, Video- und anderen elektronischen Kommunikationsmitteln, um es den Anbietern/Anbieterinnen zu ermöglichen, auf individuelle Mitgliederdaten zu Behandlungszwecken zuzugreifen. Im Rahmen dieses Verfahrens muss der jeweilige Anbieter bzw. die jeweilige Anbieterin möglicherweise Ihre Identität überprüfen und während der Sitzung Ihren Standort erfragen, um eine effektive Behandlung zu gewährleisten. Es kann vorkommen, dass einige Ihrer personenbezogenen Gesundheitsdaten bei der Interaktion mittels Video-, Audio- oder anderer Telekommunikationstechnologien zur Sprache gebracht werden. Einige Mitglieder empfinden die Fernberatung als weniger intim oder hilfreich als die traditionelle persönliche Beratung. Oftmals liegt das daran, dass es sich um eine neue Art der Kommunikation handelt. Nach der Teilnahme an mehreren Sitzungen stellen viele Mitglieder jedoch fest, dass die Telemedizin schon nützlich sein kann.  Wenn Sie jedoch zum Schluss kommen, dass Telemedizin nichts für Sie ist, sollten Sie Ihren Therapeuten bzw. Ihre Therapeutin oder Spring Health Care Navigator umgehend davon in Kenntnis setzen.

Erwarteter Nutzen der Telemedizin: 

• Verbesserung des Zugangs zur Gesundheitsversorgung, indem es Mitgliedern ermöglicht wird, Beratungen von einem breiteren Spektrum von Anbietern/Anbieterinnen an entfernten/anderen Orten einzuholen, die nicht für eine persönliche Betreuung aufgesucht werden können
• Effizientere Beurteilung und Verwaltung mit mehreren verfügbaren Terminen im Vergleich zur rein persönlichen Behandlung
• Bequemere Behandlungsplanung und Logistik

Mögliche Risiken der Telemedizin: 

Wie jede Art von Beurteilung und Behandlung birgt auch die Telemedizin diverse Risiken. Dazu zählen unter anderem:

• In seltenen Fällen reichen die übermittelten Informationen möglicherweise nicht aus (z. B. schlechte Konnektivität), um den Anbietern/Anbieterinnen eine angemessene Entscheidungsfindung zu ermöglichen.
• Aufgrund von Mängeln oder Ausfällen der technischen Ausrüstung können Verzögerungen bei der Beurteilung und Behandlung auftreten.
• In sehr seltenen Fällen könnten Sicherheitsprotokolle ausfallen, sodass es zu einer Offenlegung personenbezogener Daten kommt.
• In einigen Fällen kann es für die Anbieter/Anbieterinnen schwierig sein, Ihren Standort zu verfolgen und Ihre Behandlung in Notsituationen zu koordinieren.
• In einigen Fällen müssen sich eventuell mehrere Personen an Ihrer Behandlung beteiligen, um den idealen Behandlungsplan festzulegen.

Elektronische Informationen/Systeme:

Die von den Anbietern/Anbieterinnen während Ihrer Sitzungen gesammelten elektronischen Daten können für Beratungs-, Nachsorge- und Schulungszwecke verwendet werden und Folgendes beinhalten:

• Mitgliederakten und elektronischer Schriftverkehr/Schriftverkehr in Papierform
• Bidirektionale Live-Audio und -Videoaufnahmen
• Ausgabedaten aus Ton- und Videodateien

Die während Ihrer Behandlung verwendeten elektronischen Systeme enthalten Netzwerk- und Softwaresicherheitsprotokolle, um die Vertraulichkeit Ihrer Identifikations- und Bilddaten zu schützen, und umfassen Maßnahmen zum Schutz der Daten ihrer Integrität vor vorsätzlichen oder unbeabsichtigten Beschädigungen.

Spring Health sendet möglicherweise elektronische Terminerinnerungen an Ihr Telefon.

Grundlegende Informationen zum Datenschutz und zur Verwaltung personenbezogener Gesundheitsdaten:

Spring Health verwendet, verarbeitet und schützt Ihre personenbezogenen Informationen und Daten gemäß der Datenschutzerklärung von Spring Health. Mit Ihrer Zustimmung genehmigen Sie die Verarbeitung Ihrer personenbezogenen Daten für die ordnungsgemäße Erbringung des Telemedizindienstes. In diesem Zusammenhang sieht Spring Health die Weitergabe Ihrer Daten an Dritte und die internationale Übertragung personenbezogener Daten vor, sofern angemessene Schutzmaßnahmen gemäß geltendem Recht getroffen werden. Ihnen steht das Recht zu, auf Ihre Daten zuzugreifen und sie bei Bedarf korrigieren und löschen zu lassen. Außerdem haben Sie noch weitere Rechte – diese sind in der oben genannten Datenschutzerklärung erläutert. Bitte wenden Sie sich an Ihren Care Navigator, wenn Sie weitere Fragen haben.

Verantwortung der Mitglieder/Richtlinie zu verpassten Terminen:

• Spring Health ist kein eingetragener Anbieter und gehört keinen staatlichen oder allgemeinen Gesundheitssystemen an.
• Hiermit erklären Sie, verstanden zu haben, dass alle Termine von Ihnen im Voraus gebucht werden müssen, um die jeweilige Behandlung zu reservieren.
• Wenn Sie einen Termin innerhalb von 24 Stunden nach einem vereinbarten Telemedizin-Termin stornieren, müssen Sie möglicherweise eine Bearbeitungsgebühr für die Stornierung bezahlen (oder es wird ein von Ihrem/Ihrer Arbeitgeber/in geförderter Termin abgezogen).
• Wenn Sie mehr als 10 Minuten zu spät zu einem Telemedizin-Therapie-Termin kommen, liegt es im Ermessen des Anbieters bzw. der Anbieterin, einen Termin abzusagen oder zu verkürzen. Im Falle einer Stornierung müssen Sie möglicherweise eine Stornogebühr wie weiter oben beschrieben entrichten.

ELTERLICHE ZUSTIMMUNG ZUR BEHANDLUNG MINDERJÄHRIGER

Zustimmung zur Behandlung

Ich, der/die Unterzeichner(in), bin ein Elternteil/eine erziehungsberechtigte Person des oben genannten Kindes und stimme hiermit seiner Teilnahme an der von Spring Care, Inc. (Spring Health) bereitgestellten Beratung zur Pflege der mentalen Gesundheit zu.

Art der Beratung

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Mir ist bewusst, dass bei einer Beratung zur Pflege der mentalen Gesundheit möglicherweise Themen erörtert werden, die für mein Kind heikel oder schwierig sind. Dazu zählen beispielsweise familiäre Beziehungen, Schulerfahrungen, das persönliche Wachstum und das emotionale Wohlbefinden. Das Ziel der Beratung besteht in der Unterstützung meines Kindes bei der Entwicklung von Bewältigungsstrategien, Verbesserung seiner emotionalen Regulierung und Stärkung seiner allgemeinen mentalen Gesundheit.

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Vertrauens-

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Mir ist bekannt, dass die Vertraulichkeit der Beratungssitzungen meines Kindes gesetzlich geschützt ist. Die während der Beratung offengelegten Informationen werden ohne meine schriftliche Zustimmung nicht an Dritte weitergegeben, außer in Fällen, in denen eine Offenlegung gesetzlich vorgeschrieben ist. Zu diesen Ausnahmen zählen Situationen, in denen die Gefahr besteht, dass meinem Kind oder anderen Personen Leid zugefügt wird, ein Verdacht auf Kindesmissbrauch vorliegt oder eine gerichtliche Anordnung erlassen wird.

Einschränkungen des Dienstes

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Mir ist bewusst, dass eine Beratung im Zusammenhang mit der mentalen Gesundheit weder eine Besserung noch ein bestimmtes Ergebnis garantieren kann. Ich habe verstanden, dass Beratungsdienste keinen Ersatz für eine medizinische Versorgung darstellen und ich bei Bedarf ärztlichen Rat einholen muss.

Elterliche Gewalt

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Indem ich dieses Konto im Namen des minderjährigen Kindes einrichte, erkläre ich Folgendes:

– Ich bin rechtlich dazu befugt, der Behandlung meines Kindes allein zuzustimmen. **ODER**

– Ich habe die Zustimmung des anderen Elternteils/der anderen erziehungsberechtigten Person bezüglich der Anmeldung meines Kindes bei einer Beratung zur Pflege der mentalen Gesundheit eingeholt.

Zustimmung und Vereinbarung

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Hiermit bestätige ich, dass ich die in dieser elterlichen Zustimmung sowie in der Zustimmung zur Behandlung dargelegten Bedingungen gelesen und verstanden habe und ihnen zustimme. Ich stimme der Teilnahme meines Kindes an der Beratung zur Pflege der mentalen Gesundheit bei Spring Health freiwillig zu.

Bei Fragen zu diesem Zustimmungsformular oder dem Beratungsverfahren wenden Sie sich bitte an careteam@springhealth.com.

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 ZUSTIMMUNG ZUR ERFASSUNG UND VERARBEITUNG VON GESUNDHEITSINFORMATIONEN

In diesem Formular wird die Erfassung und Verarbeitung Ihrer Gesundheitsdaten durch Spring Health erörtert. Diese Daten werden von uns beispielsweise erfasst, wenn Sie unsere Dienste nutzen, mit unseren Websites, mobilen Apps oder Anbietern und Anbieterinnen von Diensten zur Pflege der mentalen Gesundheit interagieren oder den Fragebogen von Spring Health zur körperlichen und/oder mentalen Gesundheit („Gesundheitsdaten“) beantworten. 

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Indem Sie auf „Zustimmen“ klicken, stimmen Sie der Erfassung und Verarbeitung Ihrer Gesundheitsinformationen ausdrücklich zu und erklären sich mit Folgendem einverstanden:

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1. Ihre Gesundheitsdaten werden verwendet, um Ihnen die Dienste bereitzustellen.

2. Das Behandlungsteam wird auf Ihre Gesundheitsdaten zugreifen. Dieses umfasst alle Anbieter(innen) von Spring Health, die Ihnen Dienste bereitstellen, Care Navigators sowie Behandlungsunterstützungsvertreter. 

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3. Ihre Gesundheitsdaten werden für unsere internen Verwaltungs- und Geschäftszwecke verwendet, beispielsweise zur Datenanalyse, Entwicklung neuer Dienste, Erweiterung, Verbesserung oder Änderung von Diensten und Ermittlung von Nutzungstrends.

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4. Weiterhin werden Ihre Gesundheitsdaten für Audits sowie die Betrugsüberwachung und -prävention verwendet.

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5. Die Verarbeitung Ihrer Gesundheitsdaten kann die Weitergabe anonymisierter und aggregierter statistischer Daten an Ihren Arbeitgeber und/oder andere Dritte durch Spring Health umfassen.

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6. Wenn Sie an einem Prämienprogramm teilnehmen, werden Ihre Gesundheitsdaten verwendet, um Ihre Prämien freizuschalten. 

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7. Des Weiteren werden Ihre Gesundheitsdaten für die Rechnungsstellung, Zahlung und Schadensabwicklung verwendet.

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8. Die Übertragung und Verarbeitung Ihrer Gesundheitsdaten erfolgt in den Vereinigten Staaten.

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Sie haben verstanden, dass es sich bei Gesundheitsinformationen um vertrauliche Informationen handelt und dass Sie nicht dazu verpflichtet sind, einer derartigen Verarbeitung zuzustimmen. Wenn Sie nicht zustimmen, können Sie möglicherweise nicht auf bestimmte Dienste zugreifen, die von Spring Health angeboten werden. Sie haben verstanden, dass Ihnen das Recht zusteht, (i) auf Ihre personenbezogenen Daten zuzugreifen, (ii) Ihre personenbezogenen Daten zu berichtigen/löschen, (iii) die Verarbeitung Ihrer personenbezogenen Daten einzuschränken und (iv) Ihre Zustimmung zur Verarbeitung Ihrer personenbezogenen Daten zu widerrufen.

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Weitere Informationen über die Verarbeitung Ihrer Gesundheitsinformationen sowie die Ihnen zustehenden Rechte finden Sie in der Datenschutzerklärung von Spring Health.

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Sie können Ihre Zustimmung widerrufen, indem Sie eine E-Mail an privacy@springhealth.com senden. 

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CONSENTIMIENTO PARA SERVICIOS

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Este formulario describe las políticas de asesoramiento y sesión de Spring Health e incluye:

Su consentimiento para recibir asesoramiento de un proveedor afiliado a Spring Health; y

Su acuerdo para recibir servicios utilizando tecnología de telesalud.

Al marcar "Acepto el consentimiento de Spring para los servicios", usted acepta que ha leído y entendido lo siguiente:

1. Entiendo que tengo el derecho de retener o retirar mi consentimiento para el uso de los servicios de telesalud en el curso de mi atención en cualquier momento.
2. Entiendo que una variedad de métodos alternativos de atención pueden estar disponibles para mí.
3. Entiendo que, en caso de tener una emergencia médica, debo comunicarme inmediatamente con mi médico personal, el sistema local de notificación de emergencias o ir a la sala de emergencias más cercana.
4. Entiendo que es mi deber informar a mi proveedor de las interacciones con respecto a mi atención que pueda tener con mis proveedores de atención médica en la medida en que sean relevantes. 
5. He leído y entiendo la información proporcionada a continuación.
6. He leído las condiciones de la política de responsabilidad/citas perdidas del miembro de Spring Health y acepto las políticas que se describen en este documento.

SERVICIOS Y POLÍTICAS RELACIONADAS DE SPRING HEALTH

Los servicios se pueden realizar utilizando la telesalud como modalidad de tratamiento. Estos servicios serán proporcionados por terapeutas que son independientes de Spring Health, incluidos profesionales con calificaciones y/o registros en los organismos profesionales aplicables necesarios para proporcionar los servicios relevantes en su país, estado o localidad, y pueden incluir psicólogos, terapeutas, asesores u otros especialistas.

Spring Health no brinda por sí misma ningún servicio o tratamiento médico o de salud de ningún tipo. Este documento es solo para fines informativos y no debe interpretarse como un consejo médico. 

Limitaciones a los tipos de evaluación

Los proveedores de Spring Health no pueden proporcionar los siguientes tipos de evaluaciones: administración de medicamentos, reincorporación al trabajo para evaluaciones de servicio, evaluaciones de custodia de los padres, tratamiento ordenado por la corte, evaluaciones de animales de apoyo emocional u otras evaluaciones administrativas similares. Los miembros pueden solicitar una copia de su registro de miembro o solicitar una carta de declaración para asistir a las sesiones.  Los miembros pueden compartir estos registros directamente con cualquier agencia de su elección. Los proveedores no enviarán sus registros directamente a ningún tercero que no esté involucrado en su atención a menos que usted haya dado su autorización por escrito.

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La telesalud como modalidad de tratamiento

La telesalud implica el uso de audio, video y otras comunicaciones electrónicas para permitir a los proveedores acceder a la información individual de los Miembros con fines de atención. Como parte de este proceso, es posible que su proveedor deba verificar su identidad y solicitar su ubicación durante una sesión para brindar una atención efectiva. Los detalles de su información médica personal pueden analizarse con usted mediante el uso de video interactivo, audio u otra tecnología de telecomunicaciones. Algunos miembros no consideran que el asesoramiento a distancia sea tan íntimo o útil como el asesoramiento tradicional en persona. A menudo, esto se debe a que es una nueva forma de comunicarse. Sin embargo, muchos Miembros descubren que, después de haber participado en varias sesiones, pueden beneficiarse del uso de la telesalud. Si decide que la telesalud no es para usted, debe notificarlo de inmediato a su terapeuta o a un Care Navigator de Spring Health.

Beneficios esperados de la telesalud:: 

• mejorar el acceso a la atención al permitir que un Miembro obtenga consultas de una gama más amplia de proveedores en sitios distantes/otros que no están disponibles para la atención en persona;
• evaluación y gestión más eficientes con una gama más amplia de disponibilidad de citas en comparación con la atención solo en persona; y
• programación y logística de atención más convenientes.

Posibles riesgos de la telesalud: 

Al igual que con cualquier evaluación y tratamiento, existen riesgos potenciales asociados con el uso de la telesalud. Estos riesgos incluyen, entre otros:

• en casos excepcionales, la información transmitida puede no ser suficiente (p. ej., conectividad deficiente) para permitir la toma de decisiones adecuada por parte de los proveedores;
• retrasos en la evaluación y el tratamiento podrían ocurrir debido a deficiencias o fallas del equipo;
• en casos muy raros, los protocolos de seguridad podrían fallar, causando una violación de la privacidad de la información personal;
• en algunos casos, puede ser difícil para los proveedores rastrear su ubicación y guiar su atención en situaciones de emergencia; y
• En algunos casos, es posible que tenga varias personas involucradas en su atención para determinar el plan de tratamiento ideal.

Información/sistemas electrónicos:

La información electrónica recopilada por los proveedores durante sus sesiones se puede utilizar para asesoramiento, seguimiento y/o educación, y puede incluir cualquiera de los siguientes:

• Registros de miembros y comunicaciones electrónicas/en papel;
• audio y video bidireccional en vivo; y/o
• datos de salida de archivos de sonido y video.

Los sistemas electrónicos utilizados en su cuidado incorporarán protocolos de seguridad de red y software para proteger la confidencialidad de sus datos de identificación e imágenes e incluirán medidas para salvaguardar los datos y garantizar su integridad contra la corrupción intencional o no intencional.

Spring Health puede enviar recordatorios electrónicos de citas a su teléfono.

Información básica sobre Protección de datos y Gestión de datos personales de salud:

Spring Health utiliza, maneja y protege su información y datos personales de acuerdo con el Aviso de privacidad de Spring Health. Con su consentimiento, usted autoriza el procesamiento de sus datos personales para la correcta prestación del servicio de telesalud. En este sentido, Spring Health prevé la comunicación de sus datos a terceros y las transferencias internacionales de datos personales, con sujeción a las garantías adecuadas de conformidad con la legislación aplicable. Tiene derecho a acceder, rectificar y suprimir los datos, así como otros derechos, tal y como se explica en el citado Aviso de Privacidad. Póngase en contacto con su Care Navigator si tiene más preguntas.

Política de responsabilidad del miembro/cita perdida:

• Spring Health no es un proveedor inscrito en ningún plan de atención médica gubernamental o universal.
• Usted entiende que debe confirmar todas las citas con anticipación para conservar su franja horaria.
• Si cancela una cita dentro de las 24 horas posteriores a una cita programada de telesalud, entonces puede ser responsable de una tarifa de procesamiento de cancelación (o se le deducirá una cita patrocinada por el empleador).
• Si llega más de 10 minutos tarde a una cita de terapia de telesalud, queda a discreción del proveedor cancelar o acortar una cita. Si se cancela, es posible que tenga que pagar una tarifa de cancelación como la indicada anteriormente.

CONSENTIMIENTO DE LOS PADRES PARA EL TRATAMIENTO DE MENORES

Consentimiento para el tratamiento

Yo, el abajo firmante, soy el padre/madre/tutor legal del menor mencionado anteriormente y por este medio doy mi consentimiento para que mi hijo participe en el asesoramiento de salud mental proporcionado a través de Spring Care, Inc. (Spring Health).

Naturaleza del asesoramiento

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Entiendo que el asesoramiento de salud mental puede implicar hablar de asuntos que pueden ser delicados o difíciles para mi hijo. Pueden incluir relaciones familiares, experiencias escolares, crecimiento personal y bienestar emocional. El objetivo del asesoramiento es ayudar a mi hijo a desarrollar estrategias de afrontamiento, mejorar la regulación emocional y mejorar la salud mental en general.

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Confidencialidad

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Entiendo que la confidencialidad de las sesiones de asesoramiento de mi hijo está protegida por la ley. La información divulgada durante el asesoramiento no se compartirá con terceros sin mi consentimiento por escrito, salvo en los casos en que la ley exija su divulgación. Estas excepciones incluyen situaciones en las que existe un riesgo de daño a mi hijo u otras personas, sospecha de abuso infantil, o según lo requiera una orden judicial.

Límites del servicio

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Entiendo que el asesoramiento de salud mental no es una garantía de mejora y que los resultados pueden variar. Acepto que los servicios de asesoramiento no sustituyen la atención médica y que debo buscar asesoramiento médico si es necesario.

Autoridad de los padres

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Al establecer esta cuenta en nombre del menor, declaro que:

- Tengo el derecho legal exclusivo de dar mi consentimiento para el tratamiento de mi hijo, **O**

- He obtenido el consentimiento del otro progenitor/tutor legal para inscribir a mi hijo en el asesoramiento de salud mental.

Consentimiento y acuerdo

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Declaro que he leído, entendido y estoy de acuerdo con los términos descritos en este consentimiento de los padres, así como el consentimiento para el tratamiento. Doy voluntariamente mi consentimiento para que mi hijo participe en el asesoramiento de salud mental con Spring Health.

Si tiene alguna pregunta o duda sobre este formulario de consentimiento o el proceso de asesoramiento, no dude en comunicarse con careteam@springhealth.com

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 CONSENTIMIENTO PARA LA RECOPILACIÓN Y PROCESAMIENTO DE INFORMACIÓN DE SALUD

Este formulario describe la recopilación y el procesamiento por parte de Spring Health de sus datos de salud proporcionados mediante una combinación de su uso de nuestros servicios, incluida la interacción con nuestros sitios web, aplicaciones móviles, proveedores de salud mental, equipo de atención y/o sus respuestas al Cuestionario de Spring Health relacionado con su salud física y/o mental (“información de salud”). 

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Al hacer clic en Aceptar, da su consentimiento explícito para la recopilación y el procesamiento de su Información de salud  y acepta y entiende que:

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1. Su información de salud se utilizará para brindarle los servicios.

2. Su equipo de atención, incluidos todos los proveedores de Spring Health que le brindan servicios, Care Navigators y representantes de apoyo a la atención, tendrán acceso a su información de salud. 

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3. Su información de salud se utilizará para nuestra gestión interna y con fines comerciales, como el análisis de datos, el desarrollo de nuevos servicios, la mejora o modificación de los servicios y la identificación de tendencias de uso.

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4. Su información de salud se utilizará para auditorías, control de fraudes y prevención.

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5. El procesamiento de su información de salud puede incluir la divulgación de información estadística anónima y agregada a su empleador y/u otros terceros por parte de Spring Health.

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6. Si participa en un programa de recompensas, su información de salud se utilizará para activar sus recompensas. 

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7. Su información de salud se utilizará para la facturación, el pago y las reclamaciones.

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8. Su información de salud se transferirá y procesará en Estados Unidos.

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Usted comprende que la información médica es información confidencial y que no está obligado a dar su consentimiento para este procesamiento. Si no da su consentimiento, es posible que no pueda acceder a ciertos servicios ofrecidos por Spring Health. Usted entiende que puede ejercer sus derechos a (i) acceder a su información personal, (ii) rectificar/borrar su información personal, (iii) restringir el procesamiento de su información personal y (iv) retirar su consentimiento para procesar su información personal.

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Más información sobre el procesamiento de su Información de salud, incluida la información sobre los derechos disponibles para usted, se establece en el Aviso de Privacidad de Spring Health .

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Puede retirar su consentimiento enviando un correo electrónico a privacy@springhealth.com 

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CCONSENTEMENT POUR LES SERVICES

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Ce formulaire décrit les politiques de Spring Health en matière de conseils et de sessions, et comprend ce qui suit :

Votre consentement à recevoir des conseils de la part d’un prestataire affilié à Spring Health ; et

Votre accord pour recevoir des services utilisant la technologie de la télésanté.

En cochant la case « J’accepte le consentement aux services de Spring », vous déclarez avoir lu et compris ce qui suit :

1. Je comprends que j’ai le droit de refuser ou de retirer à tout moment mon consentement à l’utilisation de services de télésanté dans le cadre de mes soins.
2. Je comprends que diverses méthodes alternatives de soins peuvent être disponibles pour moi.
3. Je comprends qu’en cas d’urgence médicale, je dois immédiatement contacter mon médecin personnel, le système local de notification des urgences ou me rendre aux urgences les plus proches.
4. Je comprends qu’il est de mon devoir d’informer mon prestataire des interactions concernant mes soins que je peux avoir avec mes prestataires de soins, dans la mesure où elles sont pertinentes. 
5. J’ai lu et compris les informations fournies ci-dessous.
6. J’ai lu les conditions de la politique de responsabilité des Membres et de rendez-vous manqués de Spring Health et j’accepte les politiques qui y sont décrites.

SERVICES ET POLITIQUES CONNEXES DE SPRING HEALTH 

Les services peuvent être fournis au moyen de la télésanté comme modalité de traitement.  Ces services seront fournis par des thérapeutes qui ne sont pas liés à Spring Health, notamment des professionnels qualifiés et/ou enregistrés auprès des organismes professionnels compétents pour fournir les services concernés dans votre pays, votre état ou votre localité, et qui peuvent être des psychologues, des thérapeutes, des conseillers ou tout autre spécialiste.

Spring Health ne fournit pas de services médicaux ou de soins de santé, ni de traitements d’aucune sorte. Le présent document est fourni uniquement à titre d’information et ne doit pas être interprété comme un avis médical. 

Limites relatives aux types d’évaluation

Les prestataires de Spring Health ne sont pas en mesure de fournir les types d’évaluations suivants : gestion de la médication, évaluation de l’aptitude au retour au travail, évaluation de la garde parentale, traitement imposé par le tribunal, évaluation des animaux de soutien émotionnel ou autres évaluations administratives similaires. Les membres peuvent demander une copie de leur dossier de membre ou une lettre de déclaration de présence aux sessions.  Les membres peuvent communiquer ces dossiers directement à l’organisme de leur choix. Les prestataires n’enverront pas vos dossiers directement à des tiers qui ne sont pas impliqués dans vos soins, à moins que vous n’ayez donné votre autorisation écrite.

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La télésanté comme modalité de traitement

La télésanté implique l’utilisation d’audio, de vidéo et d’autres communications électroniques pour permettre aux prestataires d’accéder aux informations individuelles des Membres dans le but de leur prodiguer des soins. Dans le cadre de ce processus, votre prestataire peut être amené à vérifier votre identité et à vous demander où vous vous trouvez au cours d’une session afin de vous fournir des soins efficaces. Les détails de vos informations de santé personnelles peuvent être discutés avec vous par le biais de la vidéo interactive, de l’audio ou d’autres technologies de télécommunication. Certains membres estiment que le conseil à distance n’est pas aussi intime ou utile que le conseil traditionnel en personne. Souvent, cela est dû au fait qu’il s’agit d’un nouveau mode de communication. Toutefois, de nombreux membres estiment qu’après avoir participé à plusieurs sessions, ils peuvent tirer profit de l’utilisation de la télésanté. Si vous décidez que la télésanté ne vous convient pas, veuillez en informer votre thérapeute ou le Spring Health Care Navigator sans délai.

Avantages attendus de Telehealth : 

• un meilleur accès aux soins en permettant à un Membre d’obtenir des consultations auprès d’un plus grand nombre de prestataires à distance ou sur d’autres sites qui ne sont pas disponibles pour des soins en personne ;
• une évaluation et une gestion plus efficaces grâce à un plus large éventail de rendez-vous disponibles, par rapport aux soins dispensés uniquement en personne ; et
• des plannings de soins et des logistiques plus pratiques.

Risques possibles de la télésanté : 

Comme pour toute évaluation et tout traitement, il y a des risques potentiels associés à l’utilisation de la télésanté. Ces risques comprennent, Ces risques comprennent, sans toutefois s’y limiter, ce qui suit :

• dans de rares cas, les informations transmises peuvent ne pas être suffisantes (par ex. mauvaise connectivité) pour permettre aux prestataires de prendre des décisions adéquates ;
• des retards dans l’évaluation et le traitement pourraient survenir en raison de déficiences ou de défaillances de l’équipement ;
• dans de très rares cas, les protocoles de sécurité pourraient échouer, entraînant une violation de la confidentialité des renseignements personnels ;
• dans certains cas, il peut être difficile pour les prestataires de suivre votre localisation et de diriger vos soins dans les situations d’urgence ; et
• dans certains cas, plusieurs personnes peuvent être impliquées dans vos soins afin de déterminer le plan de traitement idéal.

Systèmes d’information/systèmes électroniques :

Les informations électroniques recueillies par les prestataires au cours de vos sessions peuvent être utilisées à des fins de conseil, de suivi et/ou d’éducation, et peuvent comprendre les éléments suivants :

• Dossiers des membres et communications électroniques/papier ;
• Audio et vidéo bidirectionnel en direct ; et/ou
• Données de sortie des fichiers audio et vidéo.

Les systèmes électroniques utilisés dans le cadre de vos soins intègrent des protocoles de sécurité des réseaux et des logiciels afin de protéger la confidentialité de vos données d’identification et d’imagerie et comprennent des mesures visant à protéger les données et à garantir leur intégrité contre toute corruption intentionnelle ou involontaire.

Spring Health peut envoyer des rappels de rendez-vous par voie électronique sur votre téléphone.

Informations de base sur la protection des données et la gestion des données personnelles sur la santé :

Spring Health utilise, traite et protège vos renseignements personnels et vos données conformément à l’Avis de confidentialité de Spring Health. Lorsque vous donnez votre consentement, vous autorisez le traitement de vos données à caractère personnel pour la fourniture correcte du service de télésanté. À cet égard, Spring Health prévoit la communication de vos données à des tiers et les transferts internationaux de données à caractère personnel, sous réserve de garanties appropriées conformément au droit applicable. Vous avez le droit d’accéder, de rectifier et de supprimer les données, ainsi que d’autres droits, comme expliqué dans l’Avis de confidentialité susmentionnée. Pour toute question supplémentaire, veuillez contacter votre care navigator.

Politique en matière de responsabilité des membres et de rendez-vous manqués :

• Spring Health n’est inscrit à aucun programme gouvernemental ou de soins de santé universels.
• Vous comprenez que tous les rendez-vous doivent être confirmés par vous à l’avance afin de conserver votre créneau horaire.
• Si vous annulez un rendez-vous dans les 24 heures qui précèdent un rendez-vous de télésanté prévu, des frais de traitement d’annulation peuvent vous être facturés (ou un rendez-vous parrainé par l’employeur sera déduit).
• Si vous êtes en retard de plus de 10 minutes à un rendez-vous de téléthérapie, le prestataire peut décider d’annuler ou de raccourcir le rendez-vous. En cas d’annulation, des frais d’annulation peuvent être exigés, comme indiqué ci-dessus.

CONSENTMENT PARENTAL POUR TRAITEMENT FOURNIS AUX MINEURS

Consentement au traitement

Je, soussigné(e), suis le parent ou le tuteur légal de l'enfant susmentionné et je consens par la présente à ce que mon enfant participe à une consultation en santé mentale fournie par Spring Care, Inc. (Spring Health).

Nature des services de consultation

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Je comprends que des services de consultation en santé mentale peuvent impliquer d'aborder des sujets qui peuvent être sensibles ou difficiles pour mon enfant. Il peut s'agir d'aborder des sujets comme les relations familiales, les expériences scolaires, le développement personnel et le bien-être émotionnel. L'objectif des services de consultation est d'aider mon enfant à développer des stratégies d'adaptation, à améliorer sa régulation émotionnelle et à améliorer sa santé mentale en général.

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Violations de la

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Je comprends que la confidentialité des séances de consultation de mon enfant est protégée par la loi. Les informations divulguées au cours de la consultation ne seront pas communiquées à d'autres personnes sans mon consentement écrit, sauf dans les cas où la loi exige leur divulgation. Ces exceptions comprennent les situations où il y a un risque de préjudice pour mon enfant ou d'autres personnes, une suspicion de maltraitance d'enfant, ou si une décision de justice l'exige.

Limites du service

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Je comprends que les services de consultation en santé mentale ne sont pas une garantie d'amélioration et que les résultats peuvent varier. Je reconnais que les services de consultation ne remplacent pas les soins médicaux et que je dois demander l'avis d'un médecin si nécessaire.

Autorité parentale

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En ouvrant ce compte au nom de l'enfant mineur, je déclare que :

- Je suis le seul à pouvoir légalement consentir au traitement de mon enfant; **OU**

- J'ai obtenu le consentement de l'autre parent/tuteur légal pour inscrire mon enfant à un programme de consultation en santé mentale.

Consentement et accord

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Je reconnais avoir lu, compris et accepté les conditions énoncées dans le présent consentement parental ainsi que dans le Consentement au traitement. Je consens volontairement à la participation de mon enfant à des services de consultation en santé mentale avec Spring Health.

Si vous avez des questions ou des préoccupations concernant ce formulaire de consentement ou le processus lié aux services de consultation, n'hésitez pas à contacter careteam@springhealth.com

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 CONSENTEMENT À LA COLLECTE ET AU TRAITEMENT DES INFORMATIONS SUR LA SANTÉ

Ce formulaire concerne la collecte et le traitement par Spring Health de vos données de santé fournies par une combinaison de votre utilisation de nos Services, y compris votre interaction avec nos sites web, nos applications mobiles, nos prestataires de santé mentale, notre équipe de soins, et/ou vos réponses au Questionnaire Spring Health concernant votre santé physique et/ou mentale (« Informations sur la santé »). 

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En cliquant sur « Accepter », vous donnez votre consentement explicite à la collecte et au traitement de vos informations sur la santé et vous acceptez et comprenez que :

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1. Vos informations sur la santé seront utilisées pour vous fournir les Services.

2. Vos informations sur la santé seront accessibles à votre Équipe de soins, y compris à tous les prestataires de soins de santé Spring Health qui vous fournissent des Services, aux Care Navigators et aux représentants de soutien aux soins. 

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3. Vos informations sur la santé seront utilisées à des fins de gestion interne et commerciales, telles que l’analyse des données, le développement de nouveaux services, l’amélioration ou la modification des services et l’identification des tendances d’utilisation.

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4. Vos informations sur la santé seront utilisées à des fins d’audit, de contrôle des fraudes et de prévention.

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5. Le traitement de vos informations sur la santé peut inclure la divulgation d’informations statistiques anonymisées et agrégées à votre employeur et/ou à d’autres tiers par Spring Health.

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6. Si vous participez à un programme de récompenses, vos informations sur la santé seront utilisées pour activer vos récompenses. 

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7. Vos informations sur la santé seront utilisées pour la facturation, les paiements et les demandes de remboursement.

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8. Vos informations sur la santé seront transférées et traitées aux États-Unis.

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Vous comprenez que les informations sur la santé sont des informations sensibles et que vous n’êtes pas obligé de consentir à ce traitement. Si vous n’y consentez pas, il se peut que vous ne puissiez pas accéder à certains services proposés par Spring Health. Vous comprenez que vous pouvez exercer vos droits (i) d’accès à vos informations personnelles; (ii) de rectification/effacement de vos informations personnelles; (iii) de limitation du traitement de vos informations personnelles; et (iv) de retrait de votre consentement au traitement de vos informations personnelles.

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De plus amples informations sur le traitement de vos informations sur la santé, y compris sur les droits dont vous disposez, sont présentées dans l’Avis de confidentialité de Spring Health.

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Vous pouvez retirer votre consentement en envoyant un courriel à privacy@springhealth.com 

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This form describes Spring Health’s treatment and payment policies for children under 18 and includes:Your consent on behalf of the patient to receive mental health treatment from Spring Health or a Spring Health affiliated provider;Your agreement on behalf of the minor patient to receive services using telehealth technology, as applicable; andYour agreement to pay in full any charges that are your responsibility You represent that you are the patient’s parent or legal guardian and are duly authorized under state law to act on behalf of the minor. All references to “you” or “I” shall be deemed to include the minor patient where such reference applies to the individual receiving care.

By typing your name and clicking “I agree to the Terms of Service” on the Spring Health website, you agree on behalf of the minor patient:

1. I understand that the laws that protect the privacy and the confidentiality of medical information also apply to telemedicine and that no information obtained in the use of telemedicine which identifies me will be disclosed to other non-covered entities without my consent.
2. I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.
3. Subject to applicable law, I understand that I have the right to inspect medical information obtained and recorded in the course of a provider visit, and may receive copies of this information for a reasonable fee.
4. I understand that 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.
5. I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.
6. I understand that I may need to provide photo-identification and my physical location to allow for accurate and effective care to be delivered.
7. I understand that if I am having a medical emergency that I should immediately contact my personal physician, local emergency notification system, or go to the nearest emergency room.
8. I understand that it is my duty to inform my provider of interactions regarding my care that I may have with other healthcare providers.
9. I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.
10. I have read and understand the information provided below, have discussed it with my provider or such assistants as may be designated, and all of my questions have been answered to my satisfaction.
11. I hereby give my informed consent for the care outlined below and, if applicable, the use of telemedicine in my medical care.
12. I have read and understand the General Terms and Conditions below and agree to the policies outlined in this document.

General Terms and Conditions

Our services may include, without limitation, psychotherapy and medication management and may be performed using telehealth as a treatment modality. For some people, in-person psychotherapy and medication management may be available. Providers may include primary care practitioners, masters-level and doctoral-level therapists, psychiatrists or other specialists.

Psychotherapy

Often called talk therapy, this form of treatment can be helpful to individuals. Benefits can include improved mood, improved relationships, and resolution of specific problems. However, therapy is not guaranteed to work for everybody. Psychotherapy may also require exploring unpleasant aspects of your life and can, at times, lead to feelings of distress (i.e., guilt, anxiety, frustration, etc.) or a temporary increase in symptoms. These unpleasant aspects are generally temporary but are important to discuss when present. Thus, it is important to let your therapist know if you feel that your goals aren’t being met. These issues can be addressed in sessions, which typically last 50 minutes. Occasionally, therapists need to discontinue therapy. Although this is rare, if therapy ends prematurely, a suitable referral or transition will be discussed with you.

Medication Management

Medications may be indicated when your symptoms are not responsive to psychotherapy alone. When a mental illness markedly impacts your ability to work, maintain interpersonal relationships, or properly care for your basic needs, medication may offer much-needed relief. Not everyone is a good candidate for medication treatment. Such treatment requires adherence to prescribed dosing frequency and close follow-up. Your ability to adhere to medication treatment will be taken into consideration in making the decision to start such treatment. Additionally, your physician will discuss the risks, benefits, side effects, government warnings, and alternative treatments (which always includes not using medications) with you to help you determine the best treatment options available for your specific needs. Current federal law does not allow tele-providers to prescribe controlled substances without an in-person visit. If your tele-provider determines you need this type of medication, you may be referred to your primary care provider with a recommendation to prescribe this medication

Limitations to Evaluation Types

Spring providers are not able to provide the following types of evaluations: a return to work fitness for duty evaluations, parental custody evaluations, court-mandated treatment, emotional support animal evaluations, weapons purchase clearance evaluations or other similar administrative evaluations. Patients may request a copy of their patient record or ask for a statement letter for attendance at sessions. This information will be sent directly to patients. Patients can share these records directly with any agency of their choice. Spring and associated providers will not send patient records directly to any third party that is not involved in your patient care.

Consent to In-Person Care

If in-person psychotherapy or medication management services are available to you, and you chose to engage in those services, you certify that a provider has explained the nature, benefits, and potential risks of those services, and that you have been given the opportunity to ask questions about any concerns regarding the services.

Telehealth as a Treatment Modality

Telehealth involves the use of audio, video and other electronic communications to enable health care providers to access individual patient medical information for the purpose of patient care. As part of this process, your provider may need to verify your identity as well as ask your location during a session to provide effective care. Details of your medical history and personal health information may be discussed with you or other health care professionals through the use of interactive video, audio, or other telecommunications technology. Some patients do not find distance counseling to be as intimate or helpful as traditional in-person counseling. Often times, this is because it is a new way of communicating. However, once patients have participated in a couple of sessions they find that they can benefit from using telehealth. If you decide telehealth is not for you, you should promptly notify your therapist or Spring Care Navigator so an alternative, more effective mode of treatment may be arranged (by Spring and/or a third-party provider).

Expected Benefits of Telehealth:

• Improved access to medical care by enabling a patient to obtain consultations from a wider range of healthcare practitioners at distant/other sites that are not available for in-person care
• More efficient medical evaluation and management with a wider range of appointment availability compared to only in-person care
• More convenient care scheduling and logistics

Possible Risks of Telehealth:

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

• In rare cases, information transmitted may not be sufficient (e.g. poor connectivity) to allow for appropriate medical decision making by care providers;
• Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment;
• In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information;
• In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors;
• In some cases, it may be difficult for providers to track your location and guide your care in emergency situations;
• In some cases, you may have multiple individuals involved with your care to determine the ideal plan of treatment; these individuals may be psychotherapists, physicians, medical administrators, and care navigator staff.

Electronic Information/Systems:

Electronic information collected during your sessions may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:

• Patient medical records and electronic/paper communications
• Live two-way audio and video
• Output data from sound and video files
• Messaging appointment reminders to your phone

Electronic systems used in your care 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.

Personal Health Information Data Management:

Spring follows all applicable HIPAA federal guidelines in protecting and managing your data. Under HIPAA, you have a right to get a copy of your medical record, correct your medical record, ask us to limit the information we share, receive a list of those with whom we have shared your information, get a copy of this privacy notice, choose some to act for you and file a complaint if you believe your privacy rights have been violated

Under HIPAA, Spring is allowed to share your data without your consent with business associates with an HIPAA agreement in place for the following reasons: to facilitate your treatment; run our organization; bill for your services; help with public health and safety issues; do research; comply with other laws; address workers compensation, law enforcement, and other government requests; and respond to lawsuits and legal actions.

For more information on management of your protected health information contact your care navigator.

Patient Responsibility/Missed Appointment Policy:

• Spring is not an enrolled Medicaid or Medicare provider. If Spring does not participate in your health care plan, you may be responsible for greater out-of-pocket expenses than you would for an in-network service. You may submit a request for an estimate of the amount that you will be billed for the out-of-network service. Please submit your request to https://www.springhealth.com/support

• All out-of-network costs (OON) and self-pay members are required to pay the full session price on the day of session. Invoices will be delivered via email. At the end of each month, you will receive a superbill to reflect all services rendered and payments made. You can then independently submit the superbill to your insurance or coinsurance carrier for any possible reimbursements under your insurance plan.
• If Spring participates in your health care plan, you will be required to pay the in-network deductible or co-pay, according to your plan, within 24 hrs of the service rendered. Invoices will be delivered via email.
• If your employer offers a number of no cost visits per calendar year, you will be responsible for payment for any additional visits beyond those no cost offerings. Your insurance may cover a portion of those costs, as noted in the in-network and out-of-network notes above.
• Any outstanding balance is subject to a finance charge of 3% after 60 days past due.
• I understand all appointments have to be confirmed by me in advance to retain my time slot.
• If I cancel a visit within 24 hours of a scheduled telehealth visit, then I am responsible for a cancellation processing fee of $50 (or I will have an employer-sponsored visit deducted).
• If I am over 10 mins late to a telehealth therapy visit, it is up to the provider’s discretion to cancel or shorten a visit. If canceled, then I may be responsible for a cancellation fee as above.

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CONSENTIMIENTO PARA SERVICIOS

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Este formulario describe las políticas de asesoramiento y sesión de Spring Health e incluye:

Su consentimiento para recibir asesoramiento de un proveedor afiliado a Spring Health; y

Su acuerdo para recibir servicios utilizando tecnología de telesalud.

Al marcar "Acepto el consentimiento de Spring para los servicios", usted acepta que ha leído y entendido lo siguiente:

1. Entiendo que tengo el derecho de retener o retirar mi consentimiento para el uso de los servicios de telesalud en el curso de mi atención en cualquier momento.
2. Entiendo que una variedad de métodos alternativos de atención pueden estar disponibles para mí.
3. Entiendo que, en caso de tener una emergencia médica, debo comunicarme inmediatamente con mi médico personal, el sistema local de notificación de emergencias o ir a la sala de emergencias más cercana.
4. Entiendo que es mi deber informar a mi proveedor de las interacciones con respecto a mi atención que pueda tener con mis proveedores de atención médica en la medida en que sean relevantes. 
5. He leído y entiendo la información proporcionada a continuación.
6. He leído las condiciones de la política de responsabilidad/citas perdidas del miembro de Spring Health y acepto las políticas que se describen en este documento.

SERVICIOS Y POLÍTICAS RELACIONADAS DE SPRING HEALTH

Los servicios se pueden realizar utilizando la telesalud como modalidad de tratamiento. Estos servicios serán proporcionados por terapeutas que son independientes de Spring Health, incluidos profesionales con calificaciones y/o registros en los organismos profesionales aplicables necesarios para proporcionar los servicios relevantes en su país, estado o localidad, y pueden incluir psicólogos, terapeutas, asesores u otros especialistas.

Spring Health no brinda por sí misma ningún servicio o tratamiento médico o de salud de ningún tipo. Este documento es solo para fines informativos y no debe interpretarse como un consejo médico. 

Limitaciones a los tipos de evaluación

Los proveedores de Spring Health no pueden proporcionar los siguientes tipos de evaluaciones: administración de medicamentos, reincorporación al trabajo para evaluaciones de servicio, evaluaciones de custodia de los padres, tratamiento ordenado por la corte, evaluaciones de animales de apoyo emocional u otras evaluaciones administrativas similares. Los miembros pueden solicitar una copia de su registro de miembro o solicitar una carta de declaración para asistir a las sesiones.  Los miembros pueden compartir estos registros directamente con cualquier agencia de su elección. Los proveedores no enviarán sus registros directamente a ningún tercero que no esté involucrado en su atención a menos que usted haya dado su autorización por escrito.

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La telesalud como modalidad de tratamiento

La telesalud implica el uso de audio, video y otras comunicaciones electrónicas para permitir a los proveedores acceder a la información individual de los Miembros con fines de atención. Como parte de este proceso, es posible que su proveedor deba verificar su identidad y solicitar su ubicación durante una sesión para brindar una atención efectiva. Los detalles de su información médica personal pueden analizarse con usted mediante el uso de video interactivo, audio u otra tecnología de telecomunicaciones. Algunos miembros no consideran que el asesoramiento a distancia sea tan íntimo o útil como el asesoramiento tradicional en persona. A menudo, esto se debe a que es una nueva forma de comunicarse. Sin embargo, muchos Miembros descubren que, después de haber participado en varias sesiones, pueden beneficiarse del uso de la telesalud. Si decide que la telesalud no es para usted, debe notificarlo de inmediato a su terapeuta o a un Care Navigator de Spring Health.

Beneficios esperados de la telesalud:: 

• mejorar el acceso a la atención al permitir que un Miembro obtenga consultas de una gama más amplia de proveedores en sitios distantes/otros que no están disponibles para la atención en persona;
• evaluación y gestión más eficientes con una gama más amplia de disponibilidad de citas en comparación con la atención solo en persona; y
• programación y logística de atención más convenientes.

Posibles riesgos de la telesalud: 

Al igual que con cualquier evaluación y tratamiento, existen riesgos potenciales asociados con el uso de la telesalud. Estos riesgos incluyen, entre otros:

• en casos excepcionales, la información transmitida puede no ser suficiente (p. ej., conectividad deficiente) para permitir la toma de decisiones adecuada por parte de los proveedores;
• retrasos en la evaluación y el tratamiento podrían ocurrir debido a deficiencias o fallas del equipo;
• en casos muy raros, los protocolos de seguridad podrían fallar, causando una violación de la privacidad de la información personal;
• en algunos casos, puede ser difícil para los proveedores rastrear su ubicación y guiar su atención en situaciones de emergencia; y
• En algunos casos, es posible que tenga varias personas involucradas en su atención para determinar el plan de tratamiento ideal.

Información/sistemas electrónicos:

La información electrónica recopilada por los proveedores durante sus sesiones se puede utilizar para asesoramiento, seguimiento y/o educación, y puede incluir cualquiera de los siguientes:

• Registros de miembros y comunicaciones electrónicas/en papel;
• audio y video bidireccional en vivo; y/o
• datos de salida de archivos de sonido y video.

Los sistemas electrónicos utilizados en su cuidado incorporarán protocolos de seguridad de red y software para proteger la confidencialidad de sus datos de identificación e imágenes e incluirán medidas para salvaguardar los datos y garantizar su integridad contra la corrupción intencional o no intencional.

Spring Health puede enviar recordatorios electrónicos de citas a su teléfono.

Información básica sobre Protección de datos y Gestión de datos personales de salud:

Spring Health utiliza, maneja y protege su información y datos personales de acuerdo con el Aviso de privacidad de Spring Health. Con su consentimiento, usted autoriza el procesamiento de sus datos personales para la correcta prestación del servicio de telesalud. En este sentido, Spring Health prevé la comunicación de sus datos a terceros y las transferencias internacionales de datos personales, con sujeción a las garantías adecuadas de conformidad con la legislación aplicable. Tiene derecho a acceder, rectificar y suprimir los datos, así como otros derechos, tal y como se explica en el citado Aviso de Privacidad. Póngase en contacto con su Care Navigator si tiene más preguntas.

Política de responsabilidad del miembro/cita perdida:

• Spring Health no es un proveedor inscrito en ningún plan de atención médica gubernamental o universal.
• Usted entiende que debe confirmar todas las citas con anticipación para conservar su franja horaria.
• Si cancela una cita dentro de las 24 horas posteriores a una cita programada de telesalud, entonces puede ser responsable de una tarifa de procesamiento de cancelación (o se le deducirá una cita patrocinada por el empleador).
• Si llega más de 10 minutos tarde a una cita de terapia de telesalud, queda a discreción del proveedor cancelar o acortar una cita. Si se cancela, es posible que tenga que pagar una tarifa de cancelación como la indicada anteriormente.

CONSENTIMIENTO DE LOS PADRES PARA EL TRATAMIENTO DE MENORES

Consentimiento para el tratamiento

Yo, el abajo firmante, soy el padre/madre/tutor legal del menor mencionado anteriormente y por este medio doy mi consentimiento para que mi hijo participe en el asesoramiento de salud mental proporcionado a través de Spring Care, Inc. (Spring Health).

Naturaleza del asesoramiento

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Entiendo que el asesoramiento de salud mental puede implicar hablar de asuntos que pueden ser delicados o difíciles para mi hijo. Pueden incluir relaciones familiares, experiencias escolares, crecimiento personal y bienestar emocional. El objetivo del asesoramiento es ayudar a mi hijo a desarrollar estrategias de afrontamiento, mejorar la regulación emocional y mejorar la salud mental en general.

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Confidencialidad

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Entiendo que la confidencialidad de las sesiones de asesoramiento de mi hijo está protegida por la ley. La información divulgada durante el asesoramiento no se compartirá con terceros sin mi consentimiento por escrito, salvo en los casos en que la ley exija su divulgación. Estas excepciones incluyen situaciones en las que existe un riesgo de daño a mi hijo u otras personas, sospecha de abuso infantil, o según lo requiera una orden judicial.

Límites del servicio

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Entiendo que el asesoramiento de salud mental no es una garantía de mejora y que los resultados pueden variar. Acepto que los servicios de asesoramiento no sustituyen la atención médica y que debo buscar asesoramiento médico si es necesario.

Autoridad de los padres

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Al establecer esta cuenta en nombre del menor, declaro que:

- Tengo el derecho legal exclusivo de dar mi consentimiento para el tratamiento de mi hijo, **O**

- He obtenido el consentimiento del otro progenitor/tutor legal para inscribir a mi hijo en el asesoramiento de salud mental.

Consentimiento y acuerdo

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Declaro que he leído, entendido y estoy de acuerdo con los términos descritos en este consentimiento de los padres, así como el consentimiento para el tratamiento. Doy voluntariamente mi consentimiento para que mi hijo participe en el asesoramiento de salud mental con Spring Health.

Si tiene alguna pregunta o duda sobre este formulario de consentimiento o el proceso de asesoramiento, no dude en comunicarse con careteam@springhealth.com

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 CONSENTIMIENTO PARA LA RECOPILACIÓN Y PROCESAMIENTO DE INFORMACIÓN DE SALUD

Este formulario describe la recopilación y el procesamiento por parte de Spring Health de sus datos de salud proporcionados mediante una combinación de su uso de nuestros servicios, incluida la interacción con nuestros sitios web, aplicaciones móviles, proveedores de salud mental, equipo de atención y/o sus respuestas al Cuestionario de Spring Health relacionado con su salud física y/o mental (“información de salud”). 

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Al hacer clic en Aceptar, da su consentimiento explícito para la recopilación y el procesamiento de su Información de salud  y acepta y entiende que:

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1. Su información de salud se utilizará para brindarle los servicios.

2. Su equipo de atención, incluidos todos los proveedores de Spring Health que le brindan servicios, Care Navigators y representantes de apoyo a la atención, tendrán acceso a su información de salud. 

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3. Su información de salud se utilizará para nuestra gestión interna y con fines comerciales, como el análisis de datos, el desarrollo de nuevos servicios, la mejora o modificación de los servicios y la identificación de tendencias de uso.

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4. Su información de salud se utilizará para auditorías, control de fraudes y prevención.

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5. El procesamiento de su información de salud puede incluir la divulgación de información estadística anónima y agregada a su empleador y/u otros terceros por parte de Spring Health.

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6. Si participa en un programa de recompensas, su información de salud se utilizará para activar sus recompensas. 

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7. Su información de salud se utilizará para la facturación, el pago y las reclamaciones.

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8. Su información de salud se transferirá y procesará en Estados Unidos.

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Usted comprende que la información médica es información confidencial y que no está obligado a dar su consentimiento para este procesamiento. Si no da su consentimiento, es posible que no pueda acceder a ciertos servicios ofrecidos por Spring Health. Usted entiende que puede ejercer sus derechos a (i) acceder a su información personal, (ii) rectificar/borrar su información personal, (iii) restringir el procesamiento de su información personal y (iv) retirar su consentimiento para procesar su información personal.

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Más información sobre el procesamiento de su Información de salud, incluida la información sobre los derechos disponibles para usted, se establece en el Aviso de Privacidad de Spring Health .

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Puede retirar su consentimiento enviando un correo electrónico a privacy@springhealth.com 

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This form describes Spring Health’s treatment and payment policies for children under 18 and includes:Your consent on behalf of the patient to receive mental health treatment from Spring Health or a Spring Health affiliated provider;Your agreement on behalf of the minor patient to receive services using telehealth technology, as applicable; andYour agreement to pay in full any charges that are your responsibility You represent that you are the patient’s parent or legal guardian and are duly authorized under state law to act on behalf of the minor. All references to “you” or “I” shall be deemed to include the minor patient where such reference applies to the individual receiving care.

By typing your name and clicking “I agree to the Terms of Service” on the Spring Health website, you agree on behalf of the minor patient:

1. I understand that the laws that protect the privacy and the confidentiality of medical information also apply to telemedicine and that no information obtained in the use of telemedicine which identifies me will be disclosed to other non-covered entities without my consent.
2. I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.
3. Subject to applicable law, I understand that I have the right to inspect medical information obtained and recorded in the course of a provider visit, and may receive copies of this information for a reasonable fee.
4. I understand that 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.
5. I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.
6. I understand that I may need to provide photo-identification and my physical location to allow for accurate and effective care to be delivered.
7. I understand that if I am having a medical emergency that I should immediately contact my personal physician, local emergency notification system, or go to the nearest emergency room.
8. I understand that it is my duty to inform my provider of interactions regarding my care that I may have with other healthcare providers.
9. I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.
10. I have read and understand the information provided below, have discussed it with my provider or such assistants as may be designated, and all of my questions have been answered to my satisfaction.
11. I hereby give my informed consent for the care outlined below and, if applicable, the use of telemedicine in my medical care.
12. I have read and understand the General Terms and Conditions below and agree to the policies outlined in this document.

General Terms and Conditions

Our services may include, without limitation, psychotherapy and medication management and may be performed using telehealth as a treatment modality. For some people, in-person psychotherapy and medication management may be available. Providers may include primary care practitioners, masters-level and doctoral-level therapists, psychiatrists or other specialists.

Psychotherapy

Often called talk therapy, this form of treatment can be helpful to individuals. Benefits can include improved mood, improved relationships, and resolution of specific problems. However, therapy is not guaranteed to work for everybody. Psychotherapy may also require exploring unpleasant aspects of your life and can, at times, lead to feelings of distress (i.e., guilt, anxiety, frustration, etc.) or a temporary increase in symptoms. These unpleasant aspects are generally temporary but are important to discuss when present. Thus, it is important to let your therapist know if you feel that your goals aren’t being met. These issues can be addressed in sessions, which typically last 50 minutes. Occasionally, therapists need to discontinue therapy. Although this is rare, if therapy ends prematurely, a suitable referral or transition will be discussed with you.

Medication Management

Medications may be indicated when your symptoms are not responsive to psychotherapy alone. When a mental illness markedly impacts your ability to work, maintain interpersonal relationships, or properly care for your basic needs, medication may offer much-needed relief. Not everyone is a good candidate for medication treatment. Such treatment requires adherence to prescribed dosing frequency and close follow-up. Your ability to adhere to medication treatment will be taken into consideration in making the decision to start such treatment. Additionally, your physician will discuss the risks, benefits, side effects, government warnings, and alternative treatments (which always includes not using medications) with you to help you determine the best treatment options available for your specific needs. Current federal law does not allow tele-providers to prescribe controlled substances without an in-person visit. If your tele-provider determines you need this type of medication, you may be referred to your primary care provider with a recommendation to prescribe this medication

Limitations to Evaluation Types

Spring providers are not able to provide the following types of evaluations: a return to work fitness for duty evaluations, parental custody evaluations, court-mandated treatment, emotional support animal evaluations, weapons purchase clearance evaluations or other similar administrative evaluations. Patients may request a copy of their patient record or ask for a statement letter for attendance at sessions. This information will be sent directly to patients. Patients can share these records directly with any agency of their choice. Spring and associated providers will not send patient records directly to any third party that is not involved in your patient care.

Consent to In-Person Care

If in-person psychotherapy or medication management services are available to you, and you chose to engage in those services, you certify that a provider has explained the nature, benefits, and potential risks of those services, and that you have been given the opportunity to ask questions about any concerns regarding the services.

Telehealth as a Treatment Modality

Telehealth involves the use of audio, video and other electronic communications to enable health care providers to access individual patient medical information for the purpose of patient care. As part of this process, your provider may need to verify your identity as well as ask your location during a session to provide effective care. Details of your medical history and personal health information may be discussed with you or other health care professionals through the use of interactive video, audio, or other telecommunications technology. Some patients do not find distance counseling to be as intimate or helpful as traditional in-person counseling. Often times, this is because it is a new way of communicating. However, once patients have participated in a couple of sessions they find that they can benefit from using telehealth. If you decide telehealth is not for you, you should promptly notify your therapist or Spring Care Navigator so an alternative, more effective mode of treatment may be arranged (by Spring and/or a third-party provider).

Expected Benefits of Telehealth:

• Improved access to medical care by enabling a patient to obtain consultations from a wider range of healthcare practitioners at distant/other sites that are not available for in-person care
• More efficient medical evaluation and management with a wider range of appointment availability compared to only in-person care
• More convenient care scheduling and logistics

Possible Risks of Telehealth:

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

• In rare cases, information transmitted may not be sufficient (e.g. poor connectivity) to allow for appropriate medical decision making by care providers;
• Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment;
• In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information;
• In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors;
• In some cases, it may be difficult for providers to track your location and guide your care in emergency situations;
• In some cases, you may have multiple individuals involved with your care to determine the ideal plan of treatment; these individuals may be psychotherapists, physicians, medical administrators, and care navigator staff.

Electronic Information/Systems:

Electronic information collected during your sessions may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:

• Patient medical records and electronic/paper communications
• Live two-way audio and video
• Output data from sound and video files
• Messaging appointment reminders to your phone

Electronic systems used in your care 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.

Personal Health Information Data Management:

Spring follows all applicable HIPAA federal guidelines in protecting and managing your data. Under HIPAA, you have a right to get a copy of your medical record, correct your medical record, ask us to limit the information we share, receive a list of those with whom we have shared your information, get a copy of this privacy notice, choose some to act for you and file a complaint if you believe your privacy rights have been violated

Under HIPAA, Spring is allowed to share your data without your consent with business associates with an HIPAA agreement in place for the following reasons: to facilitate your treatment; run our organization; bill for your services; help with public health and safety issues; do research; comply with other laws; address workers compensation, law enforcement, and other government requests; and respond to lawsuits and legal actions.

For more information on management of your protected health information contact your care navigator.

Patient Responsibility/Missed Appointment Policy:

• Spring is not an enrolled Medicaid or Medicare provider. If Spring does not participate in your health care plan, you may be responsible for greater out-of-pocket expenses than you would for an in-network service. You may submit a request for an estimate of the amount that you will be billed for the out-of-network service. Please submit your request to https://www.springhealth.com/support

• All out-of-network costs (OON) and self-pay members are required to pay the full session price on the day of session. Invoices will be delivered via email. At the end of each month, you will receive a superbill to reflect all services rendered and payments made. You can then independently submit the superbill to your insurance or coinsurance carrier for any possible reimbursements under your insurance plan.
• If Spring participates in your health care plan, you will be required to pay the in-network deductible or co-pay, according to your plan, within 24 hrs of the service rendered. Invoices will be delivered via email.
• If your employer offers a number of no cost visits per calendar year, you will be responsible for payment for any additional visits beyond those no cost offerings. Your insurance may cover a portion of those costs, as noted in the in-network and out-of-network notes above.
• Any outstanding balance is subject to a finance charge of 3% after 60 days past due.
• I understand all appointments have to be confirmed by me in advance to retain my time slot.
• If I cancel a visit within 24 hours of a scheduled telehealth visit, then I am responsible for a cancellation processing fee of $50 (or I will have an employer-sponsored visit deducted).
• If I am over 10 mins late to a telehealth therapy visit, it is up to the provider’s discretion to cancel or shorten a visit. If canceled, then I may be responsible for a cancellation fee as above.

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This form describes Spring Health’s treatment and payment policies for children under 18 and includes:Your consent on behalf of the patient to receive mental health treatment from Spring Health or a Spring Health affiliated provider;Your agreement on behalf of the minor patient to receive services using telehealth technology, as applicable; andYour agreement to pay in full any charges that are your responsibility You represent that you are the patient’s parent or legal guardian and are duly authorized under state law to act on behalf of the minor. All references to “you” or “I” shall be deemed to include the minor patient where such reference applies to the individual receiving care.

By typing your name and clicking “I agree to the Terms of Service” on the Spring Health website, you agree on behalf of the minor patient:

1. I understand that the laws that protect the privacy and the confidentiality of medical information also apply to telemedicine and that no information obtained in the use of telemedicine which identifies me will be disclosed to other non-covered entities without my consent.
2. I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.
3. Subject to applicable law, I understand that I have the right to inspect medical information obtained and recorded in the course of a provider visit, and may receive copies of this information for a reasonable fee.
4. I understand that 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.
5. I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.
6. I understand that I may need to provide photo-identification and my physical location to allow for accurate and effective care to be delivered.
7. I understand that if I am having a medical emergency that I should immediately contact my personal physician, local emergency notification system, or go to the nearest emergency room.
8. I understand that it is my duty to inform my provider of interactions regarding my care that I may have with other healthcare providers.
9. I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.
10. I have read and understand the information provided below, have discussed it with my provider or such assistants as may be designated, and all of my questions have been answered to my satisfaction.
11. I hereby give my informed consent for the care outlined below and, if applicable, the use of telemedicine in my medical care.
12. I have read and understand the General Terms and Conditions below and agree to the policies outlined in this document.

General Terms and Conditions

Our services may include, without limitation, psychotherapy and medication management and may be performed using telehealth as a treatment modality. For some people, in-person psychotherapy and medication management may be available. Providers may include primary care practitioners, masters-level and doctoral-level therapists, psychiatrists or other specialists.

Psychotherapy

Often called talk therapy, this form of treatment can be helpful to individuals. Benefits can include improved mood, improved relationships, and resolution of specific problems. However, therapy is not guaranteed to work for everybody. Psychotherapy may also require exploring unpleasant aspects of your life and can, at times, lead to feelings of distress (i.e., guilt, anxiety, frustration, etc.) or a temporary increase in symptoms. These unpleasant aspects are generally temporary but are important to discuss when present. Thus, it is important to let your therapist know if you feel that your goals aren’t being met. These issues can be addressed in sessions, which typically last 50 minutes. Occasionally, therapists need to discontinue therapy. Although this is rare, if therapy ends prematurely, a suitable referral or transition will be discussed with you.

Medication Management

Medications may be indicated when your symptoms are not responsive to psychotherapy alone. When a mental illness markedly impacts your ability to work, maintain interpersonal relationships, or properly care for your basic needs, medication may offer much-needed relief. Not everyone is a good candidate for medication treatment. Such treatment requires adherence to prescribed dosing frequency and close follow-up. Your ability to adhere to medication treatment will be taken into consideration in making the decision to start such treatment. Additionally, your physician will discuss the risks, benefits, side effects, government warnings, and alternative treatments (which always includes not using medications) with you to help you determine the best treatment options available for your specific needs. Current federal law does not allow tele-providers to prescribe controlled substances without an in-person visit. If your tele-provider determines you need this type of medication, you may be referred to your primary care provider with a recommendation to prescribe this medication

Limitations to Evaluation Types

Spring providers are not able to provide the following types of evaluations: a return to work fitness for duty evaluations, parental custody evaluations, court-mandated treatment, emotional support animal evaluations, weapons purchase clearance evaluations or other similar administrative evaluations. Patients may request a copy of their patient record or ask for a statement letter for attendance at sessions. This information will be sent directly to patients. Patients can share these records directly with any agency of their choice. Spring and associated providers will not send patient records directly to any third party that is not involved in your patient care.

Consent to In-Person Care

If in-person psychotherapy or medication management services are available to you, and you chose to engage in those services, you certify that a provider has explained the nature, benefits, and potential risks of those services, and that you have been given the opportunity to ask questions about any concerns regarding the services.

Telehealth as a Treatment Modality

Telehealth involves the use of audio, video and other electronic communications to enable health care providers to access individual patient medical information for the purpose of patient care. As part of this process, your provider may need to verify your identity as well as ask your location during a session to provide effective care. Details of your medical history and personal health information may be discussed with you or other health care professionals through the use of interactive video, audio, or other telecommunications technology. Some patients do not find distance counseling to be as intimate or helpful as traditional in-person counseling. Often times, this is because it is a new way of communicating. However, once patients have participated in a couple of sessions they find that they can benefit from using telehealth. If you decide telehealth is not for you, you should promptly notify your therapist or Spring Care Navigator so an alternative, more effective mode of treatment may be arranged (by Spring and/or a third-party provider).

Expected Benefits of Telehealth:

• Improved access to medical care by enabling a patient to obtain consultations from a wider range of healthcare practitioners at distant/other sites that are not available for in-person care
• More efficient medical evaluation and management with a wider range of appointment availability compared to only in-person care
• More convenient care scheduling and logistics

Possible Risks of Telehealth:

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

• In rare cases, information transmitted may not be sufficient (e.g. poor connectivity) to allow for appropriate medical decision making by care providers;
• Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment;
• In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information;
• In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors;
• In some cases, it may be difficult for providers to track your location and guide your care in emergency situations;
• In some cases, you may have multiple individuals involved with your care to determine the ideal plan of treatment; these individuals may be psychotherapists, physicians, medical administrators, and care navigator staff.

Electronic Information/Systems:

Electronic information collected during your sessions may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:

• Patient medical records and electronic/paper communications
• Live two-way audio and video
• Output data from sound and video files
• Messaging appointment reminders to your phone

Electronic systems used in your care 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.

Personal Health Information Data Management:

Spring follows all applicable HIPAA federal guidelines in protecting and managing your data. Under HIPAA, you have a right to get a copy of your medical record, correct your medical record, ask us to limit the information we share, receive a list of those with whom we have shared your information, get a copy of this privacy notice, choose some to act for you and file a complaint if you believe your privacy rights have been violated

Under HIPAA, Spring is allowed to share your data without your consent with business associates with an HIPAA agreement in place for the following reasons: to facilitate your treatment; run our organization; bill for your services; help with public health and safety issues; do research; comply with other laws; address workers compensation, law enforcement, and other government requests; and respond to lawsuits and legal actions.

For more information on management of your protected health information contact your care navigator.

Patient Responsibility/Missed Appointment Policy:

• Spring is not an enrolled Medicaid or Medicare provider. If Spring does not participate in your health care plan, you may be responsible for greater out-of-pocket expenses than you would for an in-network service. You may submit a request for an estimate of the amount that you will be billed for the out-of-network service. Please submit your request to https://www.springhealth.com/support

• All out-of-network costs (OON) and self-pay members are required to pay the full session price on the day of session. Invoices will be delivered via email. At the end of each month, you will receive a superbill to reflect all services rendered and payments made. You can then independently submit the superbill to your insurance or coinsurance carrier for any possible reimbursements under your insurance plan.
• If Spring participates in your health care plan, you will be required to pay the in-network deductible or co-pay, according to your plan, within 24 hrs of the service rendered. Invoices will be delivered via email.
• If your employer offers a number of no cost visits per calendar year, you will be responsible for payment for any additional visits beyond those no cost offerings. Your insurance may cover a portion of those costs, as noted in the in-network and out-of-network notes above.
• Any outstanding balance is subject to a finance charge of 3% after 60 days past due.
• I understand all appointments have to be confirmed by me in advance to retain my time slot.
• If I cancel a visit within 24 hours of a scheduled telehealth visit, then I am responsible for a cancellation processing fee of $50 (or I will have an employer-sponsored visit deducted).
• If I am over 10 mins late to a telehealth therapy visit, it is up to the provider’s discretion to cancel or shorten a visit. If canceled, then I may be responsible for a cancellation fee as above.

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CONSENTIMENTO PARA SERVIÇOS

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Este formulário descreve as políticas de aconselhamento e sessão da Spring Health e inclui:

Seu consentimento para receber aconselhamento de um provedor afiliado à Spring Health; e

Seu acordo para receber serviços usando a tecnologia de telemedicina.

Ao marcar “Concordo com o consentimento da Spring para serviços”, você concorda que leu e entendeu o seguinte:

1. Eu entendo que tenho o direito de reter ou retirar meu consentimento para o uso de serviços de telemedicina durante meu atendimento a qualquer momento.
2. Eu entendo que vários métodos alternativos de tratamento podem estar disponíveis para mim.
3. Eu entendo que, se eu estiver passando por uma emergência médica, devo entrar em contato imediatamente com meu médico pessoal, com o sistema de notificação de emergência local ou ir ao pronto-socorro mais próximo.
4. Eu entendo que é meu dever informar meu provedor sobre as interações relacionadas ao meu atendimento que eu possa ter com meus provedores de saúde, na medida em que sejam relevantes. 
5. Eu li e entendi as informações fornecidas abaixo.
6. Eu li as condições da política de responsabilidade/consulta perdida do Membro da Spring Health e concordo com as políticas descritas aqui.

SERVIÇOS DA SPRING HEALTH E POLÍTICAS RELACIONADAS

Os serviços podem ser realizados usando telemedicina como modalidade de tratamento. Esses serviços serão fornecidos por terapeutas independentes da Spring Health, incluindo profissionais com qualificações e/ou registros nos órgãos profissionais aplicáveis necessários para fornecer os serviços relevantes em seu país, estado ou localidade, e podem incluir psicólogos, terapeutas, conselheiros ou outros especialistas.

A Spring Health, por si só, não fornece nenhum serviço médico ou de saúde ou tratamento de qualquer tipo. Este documento serve apenas para fins informativos e não deve ser interpretado como aconselhamento médico. 

Limitações aos tipos de avaliação

Os provedores da Spring Health não podem fornecer os seguintes tipos de avaliações: gerenciamento de medicamentos, avaliações de aptidão para o retorno ao trabalho, avaliações de custódia parental, tratamento exigido pelo tribunal, avaliações de animais de apoio emocional ou outras avaliações administrativas semelhantes. Os membros podem solicitar uma cópia de seu registro de membro ou uma carta de declaração para participação nas sessões.  Os membros podem compartilhar esses registros diretamente com qualquer agência de sua escolha. Os provedores não enviarão seus registros diretamente a terceiros que não estejam envolvidos em seu atendimento, a menos que você tenha dado tal autorização por escrito.

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Telemedicina como modalidade de tratamento

A telemedicina envolve o uso de áudio, vídeo e outras comunicações eletrônicas para permitir que os provedores acessem informações individuais dos membros para fins de atendimento. Como parte desse processo, seu provedor pode precisar verificar sua identidade e perguntar sua localização durante uma sessão para fornecer um atendimento eficaz. Detalhes de suas informações pessoais de saúde podem ser discutidos com você por meio do uso de vídeo interativo, áudio ou outra tecnologia de telecomunicações. Alguns membros não consideram o aconselhamento à distância tão íntimo ou útil quanto o aconselhamento presencial tradicional. Muitas vezes, isso ocorre por se tratar de uma nova forma de comunicação. No entanto, muitos membros descobrem que, depois de participarem de várias sessões, podem se beneficiar do uso da telemedicina. Se você decidir que a telemedicina não é para você, você deve notificar imediatamente seu terapeuta ou seu Spring Health Care Navigator.

Benefícios esperados da telemedicina: 

• melhor acesso ao atendimento, permitindo que um membro obtenha consultas de uma maior variedade de profissionais em locais distantes/outros que não estejam disponíveis para atendimento presencial;
• avaliação e gerenciamento mais eficientes com uma maior variedade de disponibilidade de consultas em comparação com o atendimento apenas presencial; e
• agendamento e logística de atendimento mais convenientes.

Possíveis riscos da telemedicina: 

Como em qualquer avaliação e tratamento, existem riscos potenciais associados ao uso da telemedicina. Esses riscos incluem, mas podem não estar limitados a:

• em casos raros, as informações transmitidas podem não ser suficientes (por exemplo, conectividade deficiente) para permitir a tomada de decisão apropriada pelos provedores;
• atrasos na avaliação e no tratamento podem ocorrer devido a deficiências ou falhas do equipamento;
• em casos muito raros, os protocolos de segurança podem falhar, causando uma violação da privacidade das informações pessoais;
• em alguns casos, pode ser difícil para os provedores rastrear sua localização e orientar seus cuidados em situações de emergência; e
• em alguns casos, você pode ter várias pessoas envolvidas em seus cuidados para determinar o plano de tratamento ideal.

Informações/Sistemas eletrônicos:

As informações eletrônicas coletadas pelos provedores durante suas sessões podem ser usadas para aconselhamento, acompanhamento e/ou educação e podem incluir qualquer um dos seguintes:

• Registros de membros e comunicações eletrônicas/em papel;
• áudio e vídeo bidirecionais ao vivo; e/ou
• dados de saída de arquivos de som e vídeo.

Os sistemas eletrônicos usados sob seus cuidados incorporarão protocolos de segurança de rede e software para proteger a confidencialidade de seus dados de identificação e imagem, e incluirão medidas para proteger os dados e garantir sua integridade contra corrupção intencional ou não.

A Spring Health pode enviar lembretes eletrônicos de consultas para o seu telefone.

Informações básicas sobre proteção de dados e gerenciamento de dados de informações pessoais de saúde:

A Spring Health usa, manipula e protege suas informações e dados pessoais de acordo com o Aviso de Privacidade da Spring Health. Com o seu consentimento, você autoriza o processamento de seus dados pessoais para a prestação adequada do serviço de telemedicina. Nesse sentido, a Spring Health prevê a comunicação de seus dados a terceiros e as transferências internacionais de dados pessoais, sujeitas às salvaguardas apropriadas de acordo com a lei aplicável. Você tem o direito de acessar, retificar e apagar dados, bem como outros direitos, conforme explicado no Aviso de Privacidade mencionado acima. Entre em contato com seu care navigator se tiver mais perguntas.

Política de responsabilidade/consulta perdida do membro:

• A Spring Health não é uma provedora inscrita em nenhum sistema de saúde governamental ou universal.
• Você entende que todos os compromissos devem ser confirmados por você com antecedência para manter seu agendamento.
• Se você cancelar uma consulta dentro de 24 horas de uma consulta agendada de telemedicina, poderá ser responsável por uma taxa de processamento de cancelamento (ou será deduzida uma consulta patrocinada pelo empregador).
• Se você chegar mais de 10 minutos atrasado(a) para uma consulta de terapia de telemedicina, fica a critério do provedor cancelar ou encurtar uma consulta. Se cancelado, você poderá ser responsável por uma taxa de cancelamento conforme descrito acima.

CONSENTIMENTO DOS PAIS PARA TRATAMENTO DE PACIENTES DE MENOR IDADE

Consentimento para tratamento

Eu, abaixo assinado, sou pai/mãe/responsável legal da criança acima mencionada e, por meio deste, autorizo a participação de meu filho/minha filha no aconselhamento de saúde mental prestado pela Spring Care, Inc. (Spring Health).

Natureza do aconselhamento

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Entendo que o aconselhamento de saúde mental pode envolver a discussão de questões que podem ser sensíveis ou difíceis para meu filho/minha filha. Essas questões podem incluir relacionamentos familiares, experiências escolares, crescimento pessoal e bem-estar emocional. O objetivo do aconselhamento é ajudar meu filho/minha filha a desenvolver estratégias de enfrentamento, melhorar sua regulamentação emocional e aumentar a saúde mental geral.

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Violações de

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Eu entendo que a confidencialidade das sessões de aconselhamento de meu filho/minha flha é protegida por lei. As informações divulgadas durante o aconselhamento não serão repassadas para outras pessoas sem o meu consentimento por escrito, exceto nos casos em que a lei exigir a divulgação. Essas exceções incluem situações em que exista risco de prejuízo ao meu filho/minha filha ou a outras pessoas, suspeita de abuso infantil, ou quando a divulgação for determinada por uma ordem judicial.

Limites de serviço

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Eu entendo que o aconselhamento de saúde mental não é uma garantia de melhoria e que os resultados podem variar. Eu reconheço que serviços de aconselhamento não substituem atendimento médico e que devo procurar orientação médica, se necessário.

Autoridade parental

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Ao estabelecer esta conta em nome de um filho(a) menor de idade, declaro que:

- Eu tenho direito legal exclusivo de consentir com o tratamento para meu filho/minha filha; **OU**

- Eu obtive o consentimento de outro pai/mãe/responsável legal para matricular meu filho/minha filha no aconselhamento de saúde mental.

Consentimento e anuência

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Reconheço e confirmo que li, entendi e estou de acordo com os termos presentes neste consentimento parental e no Consentimento para Tratamento. Eu voluntariamente concordo que meu filho/minha filha participe do aconselhamento em saúde mental com a Spring Health.

Em caso de quaisquer dúvidas ou preocupações sobre este formulário de consentimento ou sobre o processo de aconselhamento, fique à vontade para entrar em contato pelo e-mail careteam@springhealth.com

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 CONSENTIMENTO PARA COLETA E PROCESSAMENTO DE INFORMAÇÕES DE SAÚDE

Este formulário descreve a coleta e o processamento pela Spring Health de seus dados de saúde fornecidos por meio de uma combinação de seu uso de nossos Serviços, incluindo envolvimento com nossos sites, aplicativos móveis, provedores de saúde mental, equipe de atendimento e/ou suas respostas ao questionário da Spring Health relacionado à sua saúde física e/ou mental  (“Informações de saúde”). 

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Ao clicar em Concordo, você dá consentimento explícito para a coleta e processamento de suas Informações de saúde e concorda e compreende que:

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1. Suas informações de saúde serão usadas para lhe fornecer os Serviços.

2. Suas informações de saúde serão acessadas por sua equipe de atendimento, incluindo todos e quaisquer provedores da Spring Health que lhe forneçam serviços, Care Navigators e representantes de suporte de atendimento. 

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3. Suas informações de saúde serão usadas para nosso gerenciamento interno e para fins comerciais, como análise de dados, desenvolvimento de novos serviços, aprimoramento, melhorias ou modificação de serviços e identificação de tendências de uso.

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4. Suas informações de saúde serão usadas para auditorias, monitoramento e prevenção de fraudes.

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5. O processamento de suas informações de saúde pode incluir a divulgação de informações estatísticas anonimizadas e agregadas ao seu empregador e/ou a terceiros pela Spring Health.

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6. Se você é participante de um Programa de Recompensas, suas informações de saúde serão usadas para habilitar suas recompensas. 

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7. Suas informações de saúde serão usadas para fins de cobrança, pagamento e reivindicações de seguro.

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8. Suas informações de saúde serão transferidas e processadas nos Estados Unidos.

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Você entende que as informações de saúde são informações confidenciais e que você não é obrigado(a) a consentir com esse processamento. Se você não consentir, talvez não consiga acessar determinados serviços oferecidos pela Spring Health. Você entende que pode exercer seus direitos de (i) acessar suas informações pessoais; (ii) retificar/apagar suas informações pessoais; (iii) restringir o processamento de suas informações pessoais; e (iv) retirar seu consentimento para o processamento de suas informações pessoais.

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Mais informações sobre o processamento de suas Informações de Saúde, incluindo informações sobre os direitos disponíveis para você, estão definidas no Aviso de Privacidade da Spring Health.

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Você pode retirar seu consentimento enviando um e-mail para privacy@springhealth.com 

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This form describes Spring Health’s treatment and payment policies for children under 18 and includes:Your consent on behalf of the patient to receive mental health treatment from Spring Health or a Spring Health affiliated provider;Your agreement on behalf of the minor patient to receive services using telehealth technology, as applicable; andYour agreement to pay in full any charges that are your responsibility You represent that you are the patient’s parent or legal guardian and are duly authorized under state law to act on behalf of the minor. All references to “you” or “I” shall be deemed to include the minor patient where such reference applies to the individual receiving care.

By typing your name and clicking “I agree to the Terms of Service” on the Spring Health website, you agree on behalf of the minor patient:

1. I understand that the laws that protect the privacy and the confidentiality of medical information also apply to telemedicine and that no information obtained in the use of telemedicine which identifies me will be disclosed to other non-covered entities without my consent.
2. I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.
3. Subject to applicable law, I understand that I have the right to inspect medical information obtained and recorded in the course of a provider visit, and may receive copies of this information for a reasonable fee.
4. I understand that 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.
5. I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.
6. I understand that I may need to provide photo-identification and my physical location to allow for accurate and effective care to be delivered.
7. I understand that if I am having a medical emergency that I should immediately contact my personal physician, local emergency notification system, or go to the nearest emergency room.
8. I understand that it is my duty to inform my provider of interactions regarding my care that I may have with other healthcare providers.
9. I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.
10. I have read and understand the information provided below, have discussed it with my provider or such assistants as may be designated, and all of my questions have been answered to my satisfaction.
11. I hereby give my informed consent for the care outlined below and, if applicable, the use of telemedicine in my medical care.
12. I have read and understand the General Terms and Conditions below and agree to the policies outlined in this document.

General Terms and Conditions

Our services may include, without limitation, psychotherapy and medication management and may be performed using telehealth as a treatment modality. For some people, in-person psychotherapy and medication management may be available. Providers may include primary care practitioners, masters-level and doctoral-level therapists, psychiatrists or other specialists.

Psychotherapy

Often called talk therapy, this form of treatment can be helpful to individuals. Benefits can include improved mood, improved relationships, and resolution of specific problems. However, therapy is not guaranteed to work for everybody. Psychotherapy may also require exploring unpleasant aspects of your life and can, at times, lead to feelings of distress (i.e., guilt, anxiety, frustration, etc.) or a temporary increase in symptoms. These unpleasant aspects are generally temporary but are important to discuss when present. Thus, it is important to let your therapist know if you feel that your goals aren’t being met. These issues can be addressed in sessions, which typically last 50 minutes. Occasionally, therapists need to discontinue therapy. Although this is rare, if therapy ends prematurely, a suitable referral or transition will be discussed with you.

Medication Management

Medications may be indicated when your symptoms are not responsive to psychotherapy alone. When a mental illness markedly impacts your ability to work, maintain interpersonal relationships, or properly care for your basic needs, medication may offer much-needed relief. Not everyone is a good candidate for medication treatment. Such treatment requires adherence to prescribed dosing frequency and close follow-up. Your ability to adhere to medication treatment will be taken into consideration in making the decision to start such treatment. Additionally, your physician will discuss the risks, benefits, side effects, government warnings, and alternative treatments (which always includes not using medications) with you to help you determine the best treatment options available for your specific needs. Current federal law does not allow tele-providers to prescribe controlled substances without an in-person visit. If your tele-provider determines you need this type of medication, you may be referred to your primary care provider with a recommendation to prescribe this medication

Limitations to Evaluation Types

Spring providers are not able to provide the following types of evaluations: a return to work fitness for duty evaluations, parental custody evaluations, court-mandated treatment, emotional support animal evaluations, weapons purchase clearance evaluations or other similar administrative evaluations. Patients may request a copy of their patient record or ask for a statement letter for attendance at sessions. This information will be sent directly to patients. Patients can share these records directly with any agency of their choice. Spring and associated providers will not send patient records directly to any third party that is not involved in your patient care.

Consent to In-Person Care

If in-person psychotherapy or medication management services are available to you, and you chose to engage in those services, you certify that a provider has explained the nature, benefits, and potential risks of those services, and that you have been given the opportunity to ask questions about any concerns regarding the services.

Telehealth as a Treatment Modality

Telehealth involves the use of audio, video and other electronic communications to enable health care providers to access individual patient medical information for the purpose of patient care. As part of this process, your provider may need to verify your identity as well as ask your location during a session to provide effective care. Details of your medical history and personal health information may be discussed with you or other health care professionals through the use of interactive video, audio, or other telecommunications technology. Some patients do not find distance counseling to be as intimate or helpful as traditional in-person counseling. Often times, this is because it is a new way of communicating. However, once patients have participated in a couple of sessions they find that they can benefit from using telehealth. If you decide telehealth is not for you, you should promptly notify your therapist or Spring Care Navigator so an alternative, more effective mode of treatment may be arranged (by Spring and/or a third-party provider).

Expected Benefits of Telehealth:

• Improved access to medical care by enabling a patient to obtain consultations from a wider range of healthcare practitioners at distant/other sites that are not available for in-person care
• More efficient medical evaluation and management with a wider range of appointment availability compared to only in-person care
• More convenient care scheduling and logistics

Possible Risks of Telehealth:

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

• In rare cases, information transmitted may not be sufficient (e.g. poor connectivity) to allow for appropriate medical decision making by care providers;
• Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment;
• In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information;
• In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors;
• In some cases, it may be difficult for providers to track your location and guide your care in emergency situations;
• In some cases, you may have multiple individuals involved with your care to determine the ideal plan of treatment; these individuals may be psychotherapists, physicians, medical administrators, and care navigator staff.

Electronic Information/Systems:

Electronic information collected during your sessions may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:

• Patient medical records and electronic/paper communications
• Live two-way audio and video
• Output data from sound and video files
• Messaging appointment reminders to your phone

Electronic systems used in your care 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.

Personal Health Information Data Management:

Spring follows all applicable HIPAA federal guidelines in protecting and managing your data. Under HIPAA, you have a right to get a copy of your medical record, correct your medical record, ask us to limit the information we share, receive a list of those with whom we have shared your information, get a copy of this privacy notice, choose some to act for you and file a complaint if you believe your privacy rights have been violated

Under HIPAA, Spring is allowed to share your data without your consent with business associates with an HIPAA agreement in place for the following reasons: to facilitate your treatment; run our organization; bill for your services; help with public health and safety issues; do research; comply with other laws; address workers compensation, law enforcement, and other government requests; and respond to lawsuits and legal actions.

For more information on management of your protected health information contact your care navigator.

Patient Responsibility/Missed Appointment Policy:

• Spring is not an enrolled Medicaid or Medicare provider. If Spring does not participate in your health care plan, you may be responsible for greater out-of-pocket expenses than you would for an in-network service. You may submit a request for an estimate of the amount that you will be billed for the out-of-network service. Please submit your request to https://www.springhealth.com/support

• All out-of-network costs (OON) and self-pay members are required to pay the full session price on the day of session. Invoices will be delivered via email. At the end of each month, you will receive a superbill to reflect all services rendered and payments made. You can then independently submit the superbill to your insurance or coinsurance carrier for any possible reimbursements under your insurance plan.
• If Spring participates in your health care plan, you will be required to pay the in-network deductible or co-pay, according to your plan, within 24 hrs of the service rendered. Invoices will be delivered via email.
• If your employer offers a number of no cost visits per calendar year, you will be responsible for payment for any additional visits beyond those no cost offerings. Your insurance may cover a portion of those costs, as noted in the in-network and out-of-network notes above.
• Any outstanding balance is subject to a finance charge of 3% after 60 days past due.
• I understand all appointments have to be confirmed by me in advance to retain my time slot.
• If I cancel a visit within 24 hours of a scheduled telehealth visit, then I am responsible for a cancellation processing fee of $50 (or I will have an employer-sponsored visit deducted).
• If I am over 10 mins late to a telehealth therapy visit, it is up to the provider’s discretion to cancel or shorten a visit. If canceled, then I may be responsible for a cancellation fee as above.

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CONSENTEMENT AUX SERVICES

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Ce formulaire décrit les politiques de Spring Health concernant les conseils et les séances, et il inclut :

votre consentement à recevoir des conseils de la part d’un prestataire affilié à Spring Health;

votre accord pour recevoir des services au moyen de la technologie de télésanté.

En cochant la case « J’accepte et consens à recevoir les services de Spring », vous reconnaissez avoir lu et compris ce qui suit :

1. Je comprends que j’ai le droit de refuser ou de retirer mon consentement à l’utilisation des services de télésanté dans le cadre de soins à tout moment;
2. Je comprends que diverses méthodes de soins alternatives peuvent m’être proposées;
3. Je comprends qu’en cas d’urgence médicale, je devrais immédiatement communiquer avec mon médecin personnel, mon système local de notification en cas d’urgence ou me rendre à la salle d’urgence la plus proche;
4. Je comprends qu’il est de mon devoir d’informer mon prestataire de soins de santé des interactions que je pourrais avoir avec mes prestataires de soins de santé, dans la mesure où cela est pertinent. 
5. J’ai lu et compris les renseignements fournis ci-dessous;
6. J’ai lu les dispositions de la politique de responsabilité des « Membres » de Spring Health et celle concernant les rendez-vous manqués, et j’accepte les politiques décrites dans le présent document.

SERVICES DE SPRING HEALTH ET POLITIQUES CONNEXES

Les services peuvent être fournis en utilisant la télésanté comme modalité de traitement. Ces services seront fournis par des thérapeutes indépendants de Spring Health, y compris des professionnels qualifiés ou enregistrés auprès des organismes professionnels pertinents nécessaires pour fournir les services appropriés dans votre pays, votre État ou votre localité, et ils peuvent inclure des psychologues, des thérapeutes, des conseillers ou d’autres spécialistes.

Spring Health ne fournit pas elle-même de services médicaux, de soins de santé ou de traitement de quelque nature que ce soit. Le présent document est fourni à titre d’information seulement et ne doit pas être interprété comme un avis médical. 

Limites en matière de types d’évaluation

Les prestataires de soins de santé de Spring Health ne sont pas en mesure de fournir les types d’évaluation suivants : gestion des médicaments, évaluation de l’aptitude à retourner, évaluation pour la garde des enfants, traitement ordonné par un tribunal, évaluation d’animal de soutien émotionnel ou autres évaluations administratives similaires. Les Membres peuvent demander une copie de leur dossier de membre ou demander une lettre tenant lieu de certificat de participation à des séances.  Les Membres peuvent partager ces registres directement avec l’organisme de leur choix. Les prestataires n’enverront pas vos dossiers directement à une tierce partie qui ne participe pas à vos soins, à moins que vous n’ayez donné une autorisation écrite.

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La télésanté comme modalité de traitement

La télésanté implique l’utilisation de communications audio, vidéos et autres communications électroniques pour permettre aux prestataires d’accéder aux renseignements personnels des Membres pour les besoins des soins. Dans le cadre de ce processus, pour fournir des soins efficaces, votre prestataire devra peut-être vérifier votre identité et demander votre localisation au cours d’une séance. Les détails de vos renseignements personnels de santé peuvent être abordés avec vous au moyen de la vidéo, de l’audio ou d’autres technologies de télécommunication interactives. Certains Membres estiment que recevoir des conseils à distance n’est pas aussi intime ou utile que recevoir des conseils de manière traditionnelle, en personne. Souvent, c’est parce qu’il s’agit d’une nouvelle façon de communiquer. Cependant, de nombreux Membres estiment qu’après avoir participé à plusieurs séances, l’utilisation de la télésanté peut être bénéfique. Si vous décidez que la télésanté ne vous convient pas, vous devez en informer rapidement votre thérapeute ou votre Care Navigator de Spring Health.

Avantages attendus de la télésanté : 

• amélioration de l’accès aux soins en permettant à un Membre d’obtenir des consultations auprès d’un plus large éventail de prestataires à distance ou dans d’autres lieux et qui ne sont pas disponibles pour des soins en personne;
• évaluation et gestion plus efficaces, avec un éventail plus large de possibilités en matière de rendez-vous par rapport aux soins en personne;
• planification et logistique des soins plus pratiques.

Risques possibles en matière de télésanté : 

Comme pour toute évaluation et tout traitement, il existe des risques potentiels associés à l’utilisation de la télésanté. Ces risques comprennent, sans s’y limiter :

• dans de rares cas, l’information transmise peut ne pas être suffisante (p. ex. mauvaise connectivité) pour permettre aux prestataires de prendre des décisions appropriées;
• des retards dans l’évaluation et le traitement peuvent survenir en raison de défaillances de l’équipement;
• dans de très rares cas, les protocoles de sécurité peuvent échouer, entraînant une atteinte à la vie privée impliquant des renseignements personnels;
• dans certains cas, il peut être difficile pour les prestataires de définir votre localisation et de vous orienter vers des soins dans les situations d’urgence; et
• dans certains cas, plusieurs personnes peuvent être impliquées dans vos soins, pour déterminer le plan de traitement idéal.

Systèmes et informations électroniques :

Les informations électroniques recueillies par les prestataires au cours de vos séances peuvent être utilisées à des fins de conseil, de suivi et/ou d’éducation, et peuvent inclure les éléments suivants :

• les dossiers des membres et les communications en version électronique et/ou papier;
• une communication audio et vidéo bidirectionnelle en direct; et/ou
• des données de sortie de fichiers audio et vidéos.

Les systèmes électroniques utilisés dans le cadre de vos soins intègrent des protocoles de sécurité des réseaux et logiciels pour protéger la confidentialité de vos renseignements d’identification et données d’imagerie, et comprennent des mesures pour protéger les données et assurer leur intégrité contre l’altération intentionnelle ou non intentionnelle.

Spring Health peut envoyer des rappels de rendez-vous de manière électronique sur votre téléphone.

Renseignements de base sur la protection des données et la gestion des renseignements personnels de santé

Spring Health utilise, traite et protège vos renseignements personnels et vos données conformément à l’Avis de protection des renseignements personnels de Spring Health. En donnant votre consentement, vous autorisez le traitement de vos renseignements personnels pour le bon fonctionnement du service de télésanté. À cet égard, Spring Health prévoit la communication de vos données à des tiers et le transfert transnational de renseignements personnels, dans le respect des garanties légales applicables. Vous avez le droit d’accéder, de rectifier et de supprimer les renseignements, ainsi que d’autres droits, comme expliqué dans l’Avis de protection des renseignements personnels susmentionné. Veuillez communiquer avec votre Care Navigator si vous avez d’autres questions.

Politique sur la responsabilité des membres et les rendez-vous manqués

• Spring Health n’est pas un prestataire inscrit à un régime gouvernemental ou universel de soins de santé.
• Vous comprenez que vous devez confirmer tous les rendez-vous à l’avance pour les conserver.
• Si vous annulez un rendez-vous dans les 24 heures avant une consultation de télésanté prévue, vous pouvez être redevable des frais de traitement de l’annulation (ou un rendez-vous commandité par votre employeur sera déduit).
• Si vous avez plus de 10 minutes de retard lors d’un rendez-vous de télésanté avec un thérapeute, le prestataire peut décider d’annuler ou de raccourcir ce rendez-vous. En cas d’annulation, vous pouvez être redevable des frais de traitement de l’annulation, comme indiqué ci-dessus.

CONSENTEMENT PARENTAL POUR LE TRAITEMENT DES MINEURS

Consentement relatif au traitement

Je, soussigné, suis le parent ou tuteur légal de l’enfant dont le nom est indiqué ci-dessus et je donne par la présente mon consentement à sa participation à des séances de conseil en santé mentale fournies par Spring Care, Inc. (Spring Health).

Nature des conseils

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Je comprends que le conseil en santé mentale peut impliquer d’aborder des sujets sensibles ou difficiles pour mon enfant. Cela peut inclure les relations familiales, les expériences scolaires, le développement personnel et le bien-être émotionnel. L’objectif des séances de conseil est d’aider mon enfant à développer des stratégies d’adaptation, à améliorer la régulation de ses émotions et à renforcer sa santé mentale globale.

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Violations de la

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Je comprends que la confidentialité des séances de conseil de mon enfant est protégée par la loi. Les renseignements divulgués lors des séances de conseil ne seront pas partagées avec d’autres sans mon consentement écrit, sauf dans les cas où la loi exige leur divulgation. Ces exceptions incluent les situations où il existe un risque de préjudice pour mon enfant ou pour autrui, un soupçon de maltraitance d’enfant ou une obligation légale imposée par une ordonnance d’un tribunal.

Limites des services

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Je comprends que le conseil en santé mentale ne garantit pas une amélioration et que les résultats peuvent varier. Je reconnais que les services de conseil ne sont pas un substitut aux soins médicaux et je devrais consulter un médecin si nécessaire.

Autorité parentale

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En créant ce compte au nom de l’enfant mineur, je déclare que :

- j’ai le droit légal exclusif de consentir au traitement pour mon enfant; **OU**

- j’ai obtenu le consentement de l’autre parent ou tuteur légal pour inscrire mon enfant à des séances de conseil en santé mentale.

Consentement et Accord

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Je reconnais avoir lu, compris et accepté les conditions énoncées dans ce consentement parental, ainsi que dans le Consentement relatif au traitement. Je consens volontairement à la participation de mon enfant à des séances de conseil en santé mentale avec Spring Health.

Si vous avez des questions ou des préoccupations concernant ce formulaire de consentement ou le processus de conseil, n’hésitez pas à contacter careteam@springhealth.com

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 CONSENTEMENT POUR LA COLLECTE ET LE TRAITEMENT DES DONNÉES DE SANTÉ

Ce formulaire décrit la collecte et le traitement par Spring Health de vos données de santé obtenues à la fois par l’intermédiaire de votre utilisation de nos Services, y compris l’utilisation de nos sites Web, applications mobiles, prestataires de services de santé mentale, équipe de soins ou vos réponses au Questionnaire de Spring Health relatif à votre santé physique ou mentale (« Données de santé »). 

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En cliquant sur Accepter, vous consentez explicitement à la collecte et au traitement de vos Données de Santé, et vous acceptez ce qui suit :

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1. Vos données de santé sont utilisées pour vous fournir les services.

2. Votre équipe de soins, y compris tous les prestataires de soins de santé de Spring Health qui vous fournissent des services, les Care Navigators et les représentants du soutien en matière de soins, ont accès à vos données de santé. 

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3. Vos données de santé sont utilisées à des fins de gestion interne et commerciales, comme l’analyse de données, le développement de nouveaux services, l’amélioration ou la modification des services et l’identification des tendances d’utilisation.

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4. Vos données de santé sont utilisées à des fins de vérification, de surveillance et de prévention de la fraude.

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5. Le traitement de vos Données de santé peut comprendre la divulgation par Spring Health de renseignements statistiques anonymes et agrégés à votre employeur ou à d’autres tiers.

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6. Si vous participez à un programme de récompenses, vos données de santé sont utilisées pour vous permettre de recevoir vos récompenses. 

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7. Vos données de santé sont utilisées pour la facturation, les paiements et les demandes de remboursement.

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8. Vos données de santé sont transférées vers et traitées aux États-Unis.

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Vous comprenez que les Données de santé sont des renseignements de nature délicate et que vous n’êtes pas obligé de consentir à ce traitement. Si vous n’y consentez pas, vous pourriez ne pas être en mesure d’accéder à certains des services proposés par Spring Health. Vous comprenez que vous pouvez exercer vos droits (i) d’accéder à vos renseignements personnels; (ii) de rectifier ou de supprimer vos renseignements personnels; (iii) de restreindre le traitement de vos renseignements personnels; et (iv) de retirer votre consentement au traitement de vos renseignements personnels.

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Plus d’informations sur le traitement de vos Données de santé, y compris les renseignements sur les droits dont vous disposez, figurent dans l’Avis de protection des renseignements personnels de Spring Health.

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Vous pouvez retirer votre consentement en envoyant un courriel à l’adresse privacy@springhealth.com 

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This form describes Spring Health’s treatment and payment policies for children under 18 and includes:Your consent on behalf of the patient to receive mental health treatment from Spring Health or a Spring Health affiliated provider;Your agreement on behalf of the minor patient to receive services using telehealth technology, as applicable; andYour agreement to pay in full any charges that are your responsibility You represent that you are the patient’s parent or legal guardian and are duly authorized under state law to act on behalf of the minor. All references to “you” or “I” shall be deemed to include the minor patient where such reference applies to the individual receiving care.

By typing your name and clicking “I agree to the Terms of Service” on the Spring Health website, you agree on behalf of the minor patient:

1. I understand that the laws that protect the privacy and the confidentiality of medical information also apply to telemedicine and that no information obtained in the use of telemedicine which identifies me will be disclosed to other non-covered entities without my consent.
2. I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.
3. Subject to applicable law, I understand that I have the right to inspect medical information obtained and recorded in the course of a provider visit, and may receive copies of this information for a reasonable fee.
4. I understand that 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.
5. I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.
6. I understand that I may need to provide photo-identification and my physical location to allow for accurate and effective care to be delivered.
7. I understand that if I am having a medical emergency that I should immediately contact my personal physician, local emergency notification system, or go to the nearest emergency room.
8. I understand that it is my duty to inform my provider of interactions regarding my care that I may have with other healthcare providers.
9. I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.
10. I have read and understand the information provided below, have discussed it with my provider or such assistants as may be designated, and all of my questions have been answered to my satisfaction.
11. I hereby give my informed consent for the care outlined below and, if applicable, the use of telemedicine in my medical care.
12. I have read and understand the General Terms and Conditions below and agree to the policies outlined in this document.

General Terms and Conditions

Our services may include, without limitation, psychotherapy and medication management and may be performed using telehealth as a treatment modality. For some people, in-person psychotherapy and medication management may be available. Providers may include primary care practitioners, masters-level and doctoral-level therapists, psychiatrists or other specialists.

Psychotherapy

Often called talk therapy, this form of treatment can be helpful to individuals. Benefits can include improved mood, improved relationships, and resolution of specific problems. However, therapy is not guaranteed to work for everybody. Psychotherapy may also require exploring unpleasant aspects of your life and can, at times, lead to feelings of distress (i.e., guilt, anxiety, frustration, etc.) or a temporary increase in symptoms. These unpleasant aspects are generally temporary but are important to discuss when present. Thus, it is important to let your therapist know if you feel that your goals aren’t being met. These issues can be addressed in sessions, which typically last 50 minutes. Occasionally, therapists need to discontinue therapy. Although this is rare, if therapy ends prematurely, a suitable referral or transition will be discussed with you.

Medication Management

Medications may be indicated when your symptoms are not responsive to psychotherapy alone. When a mental illness markedly impacts your ability to work, maintain interpersonal relationships, or properly care for your basic needs, medication may offer much-needed relief. Not everyone is a good candidate for medication treatment. Such treatment requires adherence to prescribed dosing frequency and close follow-up. Your ability to adhere to medication treatment will be taken into consideration in making the decision to start such treatment. Additionally, your physician will discuss the risks, benefits, side effects, government warnings, and alternative treatments (which always includes not using medications) with you to help you determine the best treatment options available for your specific needs. Current federal law does not allow tele-providers to prescribe controlled substances without an in-person visit. If your tele-provider determines you need this type of medication, you may be referred to your primary care provider with a recommendation to prescribe this medication

Limitations to Evaluation Types

Spring providers are not able to provide the following types of evaluations: a return to work fitness for duty evaluations, parental custody evaluations, court-mandated treatment, emotional support animal evaluations, weapons purchase clearance evaluations or other similar administrative evaluations. Patients may request a copy of their patient record or ask for a statement letter for attendance at sessions. This information will be sent directly to patients. Patients can share these records directly with any agency of their choice. Spring and associated providers will not send patient records directly to any third party that is not involved in your patient care.

Consent to In-Person Care

If in-person psychotherapy or medication management services are available to you, and you chose to engage in those services, you certify that a provider has explained the nature, benefits, and potential risks of those services, and that you have been given the opportunity to ask questions about any concerns regarding the services.

Telehealth as a Treatment Modality

Telehealth involves the use of audio, video and other electronic communications to enable health care providers to access individual patient medical information for the purpose of patient care. As part of this process, your provider may need to verify your identity as well as ask your location during a session to provide effective care. Details of your medical history and personal health information may be discussed with you or other health care professionals through the use of interactive video, audio, or other telecommunications technology. Some patients do not find distance counseling to be as intimate or helpful as traditional in-person counseling. Often times, this is because it is a new way of communicating. However, once patients have participated in a couple of sessions they find that they can benefit from using telehealth. If you decide telehealth is not for you, you should promptly notify your therapist or Spring Care Navigator so an alternative, more effective mode of treatment may be arranged (by Spring and/or a third-party provider).

Expected Benefits of Telehealth:

• Improved access to medical care by enabling a patient to obtain consultations from a wider range of healthcare practitioners at distant/other sites that are not available for in-person care
• More efficient medical evaluation and management with a wider range of appointment availability compared to only in-person care
• More convenient care scheduling and logistics

Possible Risks of Telehealth:

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

• In rare cases, information transmitted may not be sufficient (e.g. poor connectivity) to allow for appropriate medical decision making by care providers;
• Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment;
• In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information;
• In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors;
• In some cases, it may be difficult for providers to track your location and guide your care in emergency situations;
• In some cases, you may have multiple individuals involved with your care to determine the ideal plan of treatment; these individuals may be psychotherapists, physicians, medical administrators, and care navigator staff.

Electronic Information/Systems:

Electronic information collected during your sessions may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:

• Patient medical records and electronic/paper communications
• Live two-way audio and video
• Output data from sound and video files
• Messaging appointment reminders to your phone

Electronic systems used in your care 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.

Personal Health Information Data Management:

Spring follows all applicable HIPAA federal guidelines in protecting and managing your data. Under HIPAA, you have a right to get a copy of your medical record, correct your medical record, ask us to limit the information we share, receive a list of those with whom we have shared your information, get a copy of this privacy notice, choose some to act for you and file a complaint if you believe your privacy rights have been violated

Under HIPAA, Spring is allowed to share your data without your consent with business associates with an HIPAA agreement in place for the following reasons: to facilitate your treatment; run our organization; bill for your services; help with public health and safety issues; do research; comply with other laws; address workers compensation, law enforcement, and other government requests; and respond to lawsuits and legal actions.

For more information on management of your protected health information contact your care navigator.

Patient Responsibility/Missed Appointment Policy:

• Spring is not an enrolled Medicaid or Medicare provider. If Spring does not participate in your health care plan, you may be responsible for greater out-of-pocket expenses than you would for an in-network service. You may submit a request for an estimate of the amount that you will be billed for the out-of-network service. Please submit your request to https://www.springhealth.com/support

• All out-of-network costs (OON) and self-pay members are required to pay the full session price on the day of session. Invoices will be delivered via email. At the end of each month, you will receive a superbill to reflect all services rendered and payments made. You can then independently submit the superbill to your insurance or coinsurance carrier for any possible reimbursements under your insurance plan.
• If Spring participates in your health care plan, you will be required to pay the in-network deductible or co-pay, according to your plan, within 24 hrs of the service rendered. Invoices will be delivered via email.
• If your employer offers a number of no cost visits per calendar year, you will be responsible for payment for any additional visits beyond those no cost offerings. Your insurance may cover a portion of those costs, as noted in the in-network and out-of-network notes above.
• Any outstanding balance is subject to a finance charge of 3% after 60 days past due.
• I understand all appointments have to be confirmed by me in advance to retain my time slot.
• If I cancel a visit within 24 hours of a scheduled telehealth visit, then I am responsible for a cancellation processing fee of $50 (or I will have an employer-sponsored visit deducted).
• If I am over 10 mins late to a telehealth therapy visit, it is up to the provider’s discretion to cancel or shorten a visit. If canceled, then I may be responsible for a cancellation fee as above.

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CONSENTIMIENTO PARA SERVICIOS

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Este formulario describe las políticas de asesoramiento y sesión de Spring Health e incluye:

Su consentimiento para recibir asesoramiento de un proveedor afiliado a Spring Health; y

Su acuerdo para recibir servicios utilizando tecnología de telesalud.

Al marcar "Acepto el consentimiento de Spring para los servicios", usted acepta que ha leído y entendido lo siguiente:

1. Entiendo que tengo el derecho de retener o retirar mi consentimiento para el uso de los servicios de telesalud en el curso de mi atención en cualquier momento.
2. Entiendo que una variedad de métodos alternativos de atención pueden estar disponibles para mí.
3. Entiendo que, en caso de tener una emergencia médica, debo comunicarme inmediatamente con mi médico personal, el sistema local de notificación de emergencias o ir a la sala de emergencias más cercana.
4. Entiendo que es mi deber informar a mi proveedor de las interacciones con respecto a mi atención que pueda tener con mis proveedores de atención médica en la medida en que sean relevantes. 
5. He leído y entiendo la información proporcionada a continuación.
6. He leído las condiciones de la política de responsabilidad/citas perdidas del miembro de Spring Health y acepto las políticas que se describen en este documento.

SERVICIOS Y POLÍTICAS RELACIONADAS DE SPRING HEALTH

Los servicios se pueden realizar utilizando la telesalud como modalidad de tratamiento. Estos servicios serán proporcionados por terapeutas que son independientes de Spring Health, incluidos profesionales con calificaciones y/o registros en los organismos profesionales aplicables necesarios para proporcionar los servicios relevantes en su país, estado o localidad, y pueden incluir psicólogos, terapeutas, asesores u otros especialistas.

Spring Health no brinda por sí misma ningún servicio o tratamiento médico o de salud de ningún tipo. Este documento es solo para fines informativos y no debe interpretarse como un consejo médico. 

Limitaciones a los tipos de evaluación

Los proveedores de Spring Health no pueden proporcionar los siguientes tipos de evaluaciones: administración de medicamentos, reincorporación al trabajo para evaluaciones de servicio, evaluaciones de custodia de los padres, tratamiento ordenado por la corte, evaluaciones de animales de apoyo emocional u otras evaluaciones administrativas similares. Los miembros pueden solicitar una copia de su registro de miembro o solicitar una carta de declaración para asistir a las sesiones.  Los miembros pueden compartir estos registros directamente con cualquier agencia de su elección. Los proveedores no enviarán sus registros directamente a ningún tercero que no esté involucrado en su atención a menos que usted haya dado su autorización por escrito.

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La telesalud como modalidad de tratamiento

La telesalud implica el uso de audio, video y otras comunicaciones electrónicas para permitir a los proveedores acceder a la información individual de los Miembros con fines de atención. Como parte de este proceso, es posible que su proveedor deba verificar su identidad y solicitar su ubicación durante una sesión para brindar una atención efectiva. Los detalles de su información médica personal pueden analizarse con usted mediante el uso de video interactivo, audio u otra tecnología de telecomunicaciones. Algunos miembros no consideran que el asesoramiento a distancia sea tan íntimo o útil como el asesoramiento tradicional en persona. A menudo, esto se debe a que es una nueva forma de comunicarse. Sin embargo, muchos Miembros descubren que, después de haber participado en varias sesiones, pueden beneficiarse del uso de la telesalud. Si decide que la telesalud no es para usted, debe notificarlo de inmediato a su terapeuta o a un Care Navigator de Spring Health.

Beneficios esperados de la telesalud:: 

• mejorar el acceso a la atención al permitir que un Miembro obtenga consultas de una gama más amplia de proveedores en sitios distantes/otros que no están disponibles para la atención en persona;
• evaluación y gestión más eficientes con una gama más amplia de disponibilidad de citas en comparación con la atención solo en persona; y
• programación y logística de atención más convenientes.

Posibles riesgos de la telesalud: 

Al igual que con cualquier evaluación y tratamiento, existen riesgos potenciales asociados con el uso de la telesalud. Estos riesgos incluyen, entre otros:

• en casos excepcionales, la información transmitida puede no ser suficiente (p. ej., conectividad deficiente) para permitir la toma de decisiones adecuada por parte de los proveedores;
• retrasos en la evaluación y el tratamiento podrían ocurrir debido a deficiencias o fallas del equipo;
• en casos muy raros, los protocolos de seguridad podrían fallar, causando una violación de la privacidad de la información personal;
• en algunos casos, puede ser difícil para los proveedores rastrear su ubicación y guiar su atención en situaciones de emergencia; y
• En algunos casos, es posible que tenga varias personas involucradas en su atención para determinar el plan de tratamiento ideal.

Información/sistemas electrónicos:

La información electrónica recopilada por los proveedores durante sus sesiones se puede utilizar para asesoramiento, seguimiento y/o educación, y puede incluir cualquiera de los siguientes:

• Registros de miembros y comunicaciones electrónicas/en papel;
• audio y video bidireccional en vivo; y/o
• datos de salida de archivos de sonido y video.

Los sistemas electrónicos utilizados en su cuidado incorporarán protocolos de seguridad de red y software para proteger la confidencialidad de sus datos de identificación e imágenes e incluirán medidas para salvaguardar los datos y garantizar su integridad contra la corrupción intencional o no intencional.

Spring Health puede enviar recordatorios electrónicos de citas a su teléfono.

Información básica sobre Protección de datos y Gestión de datos personales de salud:

Spring Health utiliza, maneja y protege su información y datos personales de acuerdo con el Aviso de privacidad de Spring Health. Con su consentimiento, usted autoriza el procesamiento de sus datos personales para la correcta prestación del servicio de telesalud. En este sentido, Spring Health prevé la comunicación de sus datos a terceros y las transferencias internacionales de datos personales, con sujeción a las garantías adecuadas de conformidad con la legislación aplicable. Tiene derecho a acceder, rectificar y suprimir los datos, así como otros derechos, tal y como se explica en el citado Aviso de Privacidad. Póngase en contacto con su Care Navigator si tiene más preguntas.

Política de responsabilidad del miembro/cita perdida:

• Spring Health no es un proveedor inscrito en ningún plan de atención médica gubernamental o universal.
• Usted entiende que debe confirmar todas las citas con anticipación para conservar su franja horaria.
• Si cancela una cita dentro de las 24 horas posteriores a una cita programada de telesalud, entonces puede ser responsable de una tarifa de procesamiento de cancelación (o se le deducirá una cita patrocinada por el empleador).
• Si llega más de 10 minutos tarde a una cita de terapia de telesalud, queda a discreción del proveedor cancelar o acortar una cita. Si se cancela, es posible que tenga que pagar una tarifa de cancelación como la indicada anteriormente.

CONSENTIMIENTO DE LOS PADRES PARA EL TRATAMIENTO DE MENORES

Consentimiento para el tratamiento

Yo, el abajo firmante, soy el padre/madre/tutor legal del menor mencionado anteriormente y por este medio doy mi consentimiento para que mi hijo participe en el asesoramiento de salud mental proporcionado a través de Spring Care, Inc. (Spring Health).

Naturaleza del asesoramiento

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Entiendo que el asesoramiento de salud mental puede implicar hablar de asuntos que pueden ser delicados o difíciles para mi hijo. Pueden incluir relaciones familiares, experiencias escolares, crecimiento personal y bienestar emocional. El objetivo del asesoramiento es ayudar a mi hijo a desarrollar estrategias de afrontamiento, mejorar la regulación emocional y mejorar la salud mental en general.

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Confidencialidad

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Entiendo que la confidencialidad de las sesiones de asesoramiento de mi hijo está protegida por la ley. La información divulgada durante el asesoramiento no se compartirá con terceros sin mi consentimiento por escrito, salvo en los casos en que la ley exija su divulgación. Estas excepciones incluyen situaciones en las que existe un riesgo de daño a mi hijo u otras personas, sospecha de abuso infantil, o según lo requiera una orden judicial.

Límites del servicio

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Entiendo que el asesoramiento de salud mental no es una garantía de mejora y que los resultados pueden variar. Acepto que los servicios de asesoramiento no sustituyen la atención médica y que debo buscar asesoramiento médico si es necesario.

Autoridad de los padres

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Al establecer esta cuenta en nombre del menor, declaro que:

- Tengo el derecho legal exclusivo de dar mi consentimiento para el tratamiento de mi hijo, **O**

- He obtenido el consentimiento del otro progenitor/tutor legal para inscribir a mi hijo en el asesoramiento de salud mental.

Consentimiento y acuerdo

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Declaro que he leído, entendido y estoy de acuerdo con los términos descritos en este consentimiento de los padres, así como el consentimiento para el tratamiento. Doy voluntariamente mi consentimiento para que mi hijo participe en el asesoramiento de salud mental con Spring Health.

Si tiene alguna pregunta o duda sobre este formulario de consentimiento o el proceso de asesoramiento, no dude en comunicarse con careteam@springhealth.com

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 CONSENTIMIENTO PARA LA RECOPILACIÓN Y PROCESAMIENTO DE INFORMACIÓN DE SALUD

Este formulario describe la recopilación y el procesamiento por parte de Spring Health de sus datos de salud proporcionados mediante una combinación de su uso de nuestros servicios, incluida la interacción con nuestros sitios web, aplicaciones móviles, proveedores de salud mental, equipo de atención y/o sus respuestas al Cuestionario de Spring Health relacionado con su salud física y/o mental (“información de salud”). 

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Al hacer clic en Aceptar, da su consentimiento explícito para la recopilación y el procesamiento de su Información de salud  y acepta y entiende que:

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1. Su información de salud se utilizará para brindarle los servicios.

2. Su equipo de atención, incluidos todos los proveedores de Spring Health que le brindan servicios, Care Navigators y representantes de apoyo a la atención, tendrán acceso a su información de salud. 

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3. Su información de salud se utilizará para nuestra gestión interna y con fines comerciales, como el análisis de datos, el desarrollo de nuevos servicios, la mejora o modificación de los servicios y la identificación de tendencias de uso.

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4. Su información de salud se utilizará para auditorías, control de fraudes y prevención.

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5. El procesamiento de su información de salud puede incluir la divulgación de información estadística anónima y agregada a su empleador y/u otros terceros por parte de Spring Health.

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6. Si participa en un programa de recompensas, su información de salud se utilizará para activar sus recompensas. 

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7. Su información de salud se utilizará para la facturación, el pago y las reclamaciones.

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8. Su información de salud se transferirá y procesará en Estados Unidos.

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Usted comprende que la información médica es información confidencial y que no está obligado a dar su consentimiento para este procesamiento. Si no da su consentimiento, es posible que no pueda acceder a ciertos servicios ofrecidos por Spring Health. Usted entiende que puede ejercer sus derechos a (i) acceder a su información personal, (ii) rectificar/borrar su información personal, (iii) restringir el procesamiento de su información personal y (iv) retirar su consentimiento para procesar su información personal.

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Más información sobre el procesamiento de su Información de salud, incluida la información sobre los derechos disponibles para usted, se establece en el Aviso de Privacidad de Spring Health .

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Puede retirar su consentimiento enviando un correo electrónico a privacy@springhealth.com 

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This form describes Spring Health’s treatment and payment policies for children under 18 and includes:Your consent on behalf of the patient to receive mental health treatment from Spring Health or a Spring Health affiliated provider;Your agreement on behalf of the minor patient to receive services using telehealth technology, as applicable; andYour agreement to pay in full any charges that are your responsibility You represent that you are the patient’s parent or legal guardian and are duly authorized under state law to act on behalf of the minor. All references to “you” or “I” shall be deemed to include the minor patient where such reference applies to the individual receiving care.

By typing your name and clicking “I agree to the Terms of Service” on the Spring Health website, you agree on behalf of the minor patient:

1. I understand that the laws that protect the privacy and the confidentiality of medical information also apply to telemedicine and that no information obtained in the use of telemedicine which identifies me will be disclosed to other non-covered entities without my consent.
2. I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.
3. Subject to applicable law, I understand that I have the right to inspect medical information obtained and recorded in the course of a provider visit, and may receive copies of this information for a reasonable fee.
4. I understand that 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.
5. I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.
6. I understand that I may need to provide photo-identification and my physical location to allow for accurate and effective care to be delivered.
7. I understand that if I am having a medical emergency that I should immediately contact my personal physician, local emergency notification system, or go to the nearest emergency room.
8. I understand that it is my duty to inform my provider of interactions regarding my care that I may have with other healthcare providers.
9. I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.
10. I have read and understand the information provided below, have discussed it with my provider or such assistants as may be designated, and all of my questions have been answered to my satisfaction.
11. I hereby give my informed consent for the care outlined below and, if applicable, the use of telemedicine in my medical care.
12. I have read and understand the General Terms and Conditions below and agree to the policies outlined in this document.

General Terms and Conditions

Our services may include, without limitation, psychotherapy and medication management and may be performed using telehealth as a treatment modality. For some people, in-person psychotherapy and medication management may be available. Providers may include primary care practitioners, masters-level and doctoral-level therapists, psychiatrists or other specialists.

Psychotherapy

Often called talk therapy, this form of treatment can be helpful to individuals. Benefits can include improved mood, improved relationships, and resolution of specific problems. However, therapy is not guaranteed to work for everybody. Psychotherapy may also require exploring unpleasant aspects of your life and can, at times, lead to feelings of distress (i.e., guilt, anxiety, frustration, etc.) or a temporary increase in symptoms. These unpleasant aspects are generally temporary but are important to discuss when present. Thus, it is important to let your therapist know if you feel that your goals aren’t being met. These issues can be addressed in sessions, which typically last 50 minutes. Occasionally, therapists need to discontinue therapy. Although this is rare, if therapy ends prematurely, a suitable referral or transition will be discussed with you.

Medication Management

Medications may be indicated when your symptoms are not responsive to psychotherapy alone. When a mental illness markedly impacts your ability to work, maintain interpersonal relationships, or properly care for your basic needs, medication may offer much-needed relief. Not everyone is a good candidate for medication treatment. Such treatment requires adherence to prescribed dosing frequency and close follow-up. Your ability to adhere to medication treatment will be taken into consideration in making the decision to start such treatment. Additionally, your physician will discuss the risks, benefits, side effects, government warnings, and alternative treatments (which always includes not using medications) with you to help you determine the best treatment options available for your specific needs. Current federal law does not allow tele-providers to prescribe controlled substances without an in-person visit. If your tele-provider determines you need this type of medication, you may be referred to your primary care provider with a recommendation to prescribe this medication

Limitations to Evaluation Types

Spring providers are not able to provide the following types of evaluations: a return to work fitness for duty evaluations, parental custody evaluations, court-mandated treatment, emotional support animal evaluations, weapons purchase clearance evaluations or other similar administrative evaluations. Patients may request a copy of their patient record or ask for a statement letter for attendance at sessions. This information will be sent directly to patients. Patients can share these records directly with any agency of their choice. Spring and associated providers will not send patient records directly to any third party that is not involved in your patient care.

Consent to In-Person Care

If in-person psychotherapy or medication management services are available to you, and you chose to engage in those services, you certify that a provider has explained the nature, benefits, and potential risks of those services, and that you have been given the opportunity to ask questions about any concerns regarding the services.

Telehealth as a Treatment Modality

Telehealth involves the use of audio, video and other electronic communications to enable health care providers to access individual patient medical information for the purpose of patient care. As part of this process, your provider may need to verify your identity as well as ask your location during a session to provide effective care. Details of your medical history and personal health information may be discussed with you or other health care professionals through the use of interactive video, audio, or other telecommunications technology. Some patients do not find distance counseling to be as intimate or helpful as traditional in-person counseling. Often times, this is because it is a new way of communicating. However, once patients have participated in a couple of sessions they find that they can benefit from using telehealth. If you decide telehealth is not for you, you should promptly notify your therapist or Spring Care Navigator so an alternative, more effective mode of treatment may be arranged (by Spring and/or a third-party provider).

Expected Benefits of Telehealth:

• Improved access to medical care by enabling a patient to obtain consultations from a wider range of healthcare practitioners at distant/other sites that are not available for in-person care
• More efficient medical evaluation and management with a wider range of appointment availability compared to only in-person care
• More convenient care scheduling and logistics

Possible Risks of Telehealth:

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

• In rare cases, information transmitted may not be sufficient (e.g. poor connectivity) to allow for appropriate medical decision making by care providers;
• Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment;
• In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information;
• In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors;
• In some cases, it may be difficult for providers to track your location and guide your care in emergency situations;
• In some cases, you may have multiple individuals involved with your care to determine the ideal plan of treatment; these individuals may be psychotherapists, physicians, medical administrators, and care navigator staff.

Electronic Information/Systems:

Electronic information collected during your sessions may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:

• Patient medical records and electronic/paper communications
• Live two-way audio and video
• Output data from sound and video files
• Messaging appointment reminders to your phone

Electronic systems used in your care 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.

Personal Health Information Data Management:

Spring follows all applicable HIPAA federal guidelines in protecting and managing your data. Under HIPAA, you have a right to get a copy of your medical record, correct your medical record, ask us to limit the information we share, receive a list of those with whom we have shared your information, get a copy of this privacy notice, choose some to act for you and file a complaint if you believe your privacy rights have been violated

Under HIPAA, Spring is allowed to share your data without your consent with business associates with an HIPAA agreement in place for the following reasons: to facilitate your treatment; run our organization; bill for your services; help with public health and safety issues; do research; comply with other laws; address workers compensation, law enforcement, and other government requests; and respond to lawsuits and legal actions.

For more information on management of your protected health information contact your care navigator.

Patient Responsibility/Missed Appointment Policy:

• Spring is not an enrolled Medicaid or Medicare provider. If Spring does not participate in your health care plan, you may be responsible for greater out-of-pocket expenses than you would for an in-network service. You may submit a request for an estimate of the amount that you will be billed for the out-of-network service. Please submit your request to https://www.springhealth.com/support

• All out-of-network costs (OON) and self-pay members are required to pay the full session price on the day of session. Invoices will be delivered via email. At the end of each month, you will receive a superbill to reflect all services rendered and payments made. You can then independently submit the superbill to your insurance or coinsurance carrier for any possible reimbursements under your insurance plan.
• If Spring participates in your health care plan, you will be required to pay the in-network deductible or co-pay, according to your plan, within 24 hrs of the service rendered. Invoices will be delivered via email.
• If your employer offers a number of no cost visits per calendar year, you will be responsible for payment for any additional visits beyond those no cost offerings. Your insurance may cover a portion of those costs, as noted in the in-network and out-of-network notes above.
• Any outstanding balance is subject to a finance charge of 3% after 60 days past due.
• I understand all appointments have to be confirmed by me in advance to retain my time slot.
• If I cancel a visit within 24 hours of a scheduled telehealth visit, then I am responsible for a cancellation processing fee of $50 (or I will have an employer-sponsored visit deducted).
• If I am over 10 mins late to a telehealth therapy visit, it is up to the provider’s discretion to cancel or shorten a visit. If canceled, then I may be responsible for a cancellation fee as above.

‍

‍

CONSENTIMIENTO PARA SERVICIOS

‍

Este formulario describe las políticas de asesoramiento y sesión de Spring Health e incluye:

Su consentimiento para recibir asesoramiento de un proveedor afiliado a Spring Health; y

Su acuerdo para recibir servicios utilizando tecnología de telesalud.

Al marcar "Acepto el consentimiento de Spring para los servicios", usted acepta que ha leído y entendido lo siguiente:

1. Entiendo que tengo el derecho de retener o retirar mi consentimiento para el uso de los servicios de telesalud en el curso de mi atención en cualquier momento.
2. Entiendo que una variedad de métodos alternativos de atención pueden estar disponibles para mí.
3. Entiendo que, en caso de tener una emergencia médica, debo comunicarme inmediatamente con mi médico personal, el sistema local de notificación de emergencias o ir a la sala de emergencias más cercana.
4. Entiendo que es mi deber informar a mi proveedor de las interacciones con respecto a mi atención que pueda tener con mis proveedores de atención médica en la medida en que sean relevantes. 
5. He leído y entiendo la información proporcionada a continuación.
6. He leído las condiciones de la política de responsabilidad/citas perdidas del miembro de Spring Health y acepto las políticas que se describen en este documento.

SERVICIOS Y POLÍTICAS RELACIONADAS DE SPRING HEALTH

Los servicios se pueden realizar utilizando la telesalud como modalidad de tratamiento. Estos servicios serán proporcionados por terapeutas que son independientes de Spring Health, incluidos profesionales con calificaciones y/o registros en los organismos profesionales aplicables necesarios para proporcionar los servicios relevantes en su país, estado o localidad, y pueden incluir psicólogos, terapeutas, asesores u otros especialistas.

Spring Health no brinda por sí misma ningún servicio o tratamiento médico o de salud de ningún tipo. Este documento es solo para fines informativos y no debe interpretarse como un consejo médico. 

Limitaciones a los tipos de evaluación

Los proveedores de Spring Health no pueden proporcionar los siguientes tipos de evaluaciones: administración de medicamentos, reincorporación al trabajo para evaluaciones de servicio, evaluaciones de custodia de los padres, tratamiento ordenado por la corte, evaluaciones de animales de apoyo emocional u otras evaluaciones administrativas similares. Los miembros pueden solicitar una copia de su registro de miembro o solicitar una carta de declaración para asistir a las sesiones.  Los miembros pueden compartir estos registros directamente con cualquier agencia de su elección. Los proveedores no enviarán sus registros directamente a ningún tercero que no esté involucrado en su atención a menos que usted haya dado su autorización por escrito.

‍

La telesalud como modalidad de tratamiento

La telesalud implica el uso de audio, video y otras comunicaciones electrónicas para permitir a los proveedores acceder a la información individual de los Miembros con fines de atención. Como parte de este proceso, es posible que su proveedor deba verificar su identidad y solicitar su ubicación durante una sesión para brindar una atención efectiva. Los detalles de su información médica personal pueden analizarse con usted mediante el uso de video interactivo, audio u otra tecnología de telecomunicaciones. Algunos miembros no consideran que el asesoramiento a distancia sea tan íntimo o útil como el asesoramiento tradicional en persona. A menudo, esto se debe a que es una nueva forma de comunicarse. Sin embargo, muchos Miembros descubren que, después de haber participado en varias sesiones, pueden beneficiarse del uso de la telesalud. Si decide que la telesalud no es para usted, debe notificarlo de inmediato a su terapeuta o a un Care Navigator de Spring Health.

Beneficios esperados de la telesalud:: 

• mejorar el acceso a la atención al permitir que un Miembro obtenga consultas de una gama más amplia de proveedores en sitios distantes/otros que no están disponibles para la atención en persona;
• evaluación y gestión más eficientes con una gama más amplia de disponibilidad de citas en comparación con la atención solo en persona; y
• programación y logística de atención más convenientes.

Posibles riesgos de la telesalud: 

Al igual que con cualquier evaluación y tratamiento, existen riesgos potenciales asociados con el uso de la telesalud. Estos riesgos incluyen, entre otros:

• en casos excepcionales, la información transmitida puede no ser suficiente (p. ej., conectividad deficiente) para permitir la toma de decisiones adecuada por parte de los proveedores;
• retrasos en la evaluación y el tratamiento podrían ocurrir debido a deficiencias o fallas del equipo;
• en casos muy raros, los protocolos de seguridad podrían fallar, causando una violación de la privacidad de la información personal;
• en algunos casos, puede ser difícil para los proveedores rastrear su ubicación y guiar su atención en situaciones de emergencia; y
• En algunos casos, es posible que tenga varias personas involucradas en su atención para determinar el plan de tratamiento ideal.

Información/sistemas electrónicos:

La información electrónica recopilada por los proveedores durante sus sesiones se puede utilizar para asesoramiento, seguimiento y/o educación, y puede incluir cualquiera de los siguientes:

• Registros de miembros y comunicaciones electrónicas/en papel;
• audio y video bidireccional en vivo; y/o
• datos de salida de archivos de sonido y video.

Los sistemas electrónicos utilizados en su cuidado incorporarán protocolos de seguridad de red y software para proteger la confidencialidad de sus datos de identificación e imágenes e incluirán medidas para salvaguardar los datos y garantizar su integridad contra la corrupción intencional o no intencional.

Spring Health puede enviar recordatorios electrónicos de citas a su teléfono.

Información básica sobre Protección de datos y Gestión de datos personales de salud:

Spring Health utiliza, maneja y protege su información y datos personales de acuerdo con el Aviso de privacidad de Spring Health. Con su consentimiento, usted autoriza el procesamiento de sus datos personales para la correcta prestación del servicio de telesalud. En este sentido, Spring Health prevé la comunicación de sus datos a terceros y las transferencias internacionales de datos personales, con sujeción a las garantías adecuadas de conformidad con la legislación aplicable. Tiene derecho a acceder, rectificar y suprimir los datos, así como otros derechos, tal y como se explica en el citado Aviso de Privacidad. Póngase en contacto con su Care Navigator si tiene más preguntas.

Política de responsabilidad del miembro/cita perdida:

• Spring Health no es un proveedor inscrito en ningún plan de atención médica gubernamental o universal.
• Usted entiende que debe confirmar todas las citas con anticipación para conservar su franja horaria.
• Si cancela una cita dentro de las 24 horas posteriores a una cita programada de telesalud, entonces puede ser responsable de una tarifa de procesamiento de cancelación (o se le deducirá una cita patrocinada por el empleador).
• Si llega más de 10 minutos tarde a una cita de terapia de telesalud, queda a discreción del proveedor cancelar o acortar una cita. Si se cancela, es posible que tenga que pagar una tarifa de cancelación como la indicada anteriormente.

CONSENTIMIENTO DE LOS PADRES PARA EL TRATAMIENTO DE MENORES

Consentimiento para el tratamiento

Yo, el abajo firmante, soy el padre/madre/tutor legal del menor mencionado anteriormente y por este medio doy mi consentimiento para que mi hijo participe en el asesoramiento de salud mental proporcionado a través de Spring Care, Inc. (Spring Health).

Naturaleza del asesoramiento

‍

Entiendo que el asesoramiento de salud mental puede implicar hablar de asuntos que pueden ser delicados o difíciles para mi hijo. Pueden incluir relaciones familiares, experiencias escolares, crecimiento personal y bienestar emocional. El objetivo del asesoramiento es ayudar a mi hijo a desarrollar estrategias de afrontamiento, mejorar la regulación emocional y mejorar la salud mental en general.

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Confidencialidad

‍

Entiendo que la confidencialidad de las sesiones de asesoramiento de mi hijo está protegida por la ley. La información divulgada durante el asesoramiento no se compartirá con terceros sin mi consentimiento por escrito, salvo en los casos en que la ley exija su divulgación. Estas excepciones incluyen situaciones en las que existe un riesgo de daño a mi hijo u otras personas, sospecha de abuso infantil, o según lo requiera una orden judicial.

Límites del servicio

‍

Entiendo que el asesoramiento de salud mental no es una garantía de mejora y que los resultados pueden variar. Acepto que los servicios de asesoramiento no sustituyen la atención médica y que debo buscar asesoramiento médico si es necesario.

Autoridad de los padres

‍

Al establecer esta cuenta en nombre del menor, declaro que:

- Tengo el derecho legal exclusivo de dar mi consentimiento para el tratamiento de mi hijo, **O**

- He obtenido el consentimiento del otro progenitor/tutor legal para inscribir a mi hijo en el asesoramiento de salud mental.

Consentimiento y acuerdo

‍

Declaro que he leído, entendido y estoy de acuerdo con los términos descritos en este consentimiento de los padres, así como el consentimiento para el tratamiento. Doy voluntariamente mi consentimiento para que mi hijo participe en el asesoramiento de salud mental con Spring Health.

Si tiene alguna pregunta o duda sobre este formulario de consentimiento o el proceso de asesoramiento, no dude en comunicarse con careteam@springhealth.com

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 CONSENTIMIENTO PARA LA RECOPILACIÓN Y PROCESAMIENTO DE INFORMACIÓN DE SALUD

Este formulario describe la recopilación y el procesamiento por parte de Spring Health de sus datos de salud proporcionados mediante una combinación de su uso de nuestros servicios, incluida la interacción con nuestros sitios web, aplicaciones móviles, proveedores de salud mental, equipo de atención y/o sus respuestas al Cuestionario de Spring Health relacionado con su salud física y/o mental (“información de salud”). 

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Al hacer clic en Aceptar, da su consentimiento explícito para la recopilación y el procesamiento de su Información de salud  y acepta y entiende que:

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1. Su información de salud se utilizará para brindarle los servicios.

2. Su equipo de atención, incluidos todos los proveedores de Spring Health que le brindan servicios, Care Navigators y representantes de apoyo a la atención, tendrán acceso a su información de salud. 

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3. Su información de salud se utilizará para nuestra gestión interna y con fines comerciales, como el análisis de datos, el desarrollo de nuevos servicios, la mejora o modificación de los servicios y la identificación de tendencias de uso.

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4. Su información de salud se utilizará para auditorías, control de fraudes y prevención.

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5. El procesamiento de su información de salud puede incluir la divulgación de información estadística anónima y agregada a su empleador y/u otros terceros por parte de Spring Health.

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6. Si participa en un programa de recompensas, su información de salud se utilizará para activar sus recompensas. 

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7. Su información de salud se utilizará para la facturación, el pago y las reclamaciones.

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8. Su información de salud se transferirá y procesará en Estados Unidos.

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Usted comprende que la información médica es información confidencial y que no está obligado a dar su consentimiento para este procesamiento. Si no da su consentimiento, es posible que no pueda acceder a ciertos servicios ofrecidos por Spring Health. Usted entiende que puede ejercer sus derechos a (i) acceder a su información personal, (ii) rectificar/borrar su información personal, (iii) restringir el procesamiento de su información personal y (iv) retirar su consentimiento para procesar su información personal.

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Más información sobre el procesamiento de su Información de salud, incluida la información sobre los derechos disponibles para usted, se establece en el Aviso de Privacidad de Spring Health .

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Puede retirar su consentimiento enviando un correo electrónico a privacy@springhealth.com 

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This form describes Spring Health’s treatment and payment policies for children under 18 and includes:Your consent on behalf of the patient to receive mental health treatment from Spring Health or a Spring Health affiliated provider;Your agreement on behalf of the minor patient to receive services using telehealth technology, as applicable; andYour agreement to pay in full any charges that are your responsibility You represent that you are the patient’s parent or legal guardian and are duly authorized under state law to act on behalf of the minor. All references to “you” or “I” shall be deemed to include the minor patient where such reference applies to the individual receiving care.

By typing your name and clicking “I agree to the Terms of Service” on the Spring Health website, you agree on behalf of the minor patient:

1. I understand that the laws that protect the privacy and the confidentiality of medical information also apply to telemedicine and that no information obtained in the use of telemedicine which identifies me will be disclosed to other non-covered entities without my consent.
2. I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.
3. Subject to applicable law, I understand that I have the right to inspect medical information obtained and recorded in the course of a provider visit, and may receive copies of this information for a reasonable fee.
4. I understand that 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.
5. I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.
6. I understand that I may need to provide photo-identification and my physical location to allow for accurate and effective care to be delivered.
7. I understand that if I am having a medical emergency that I should immediately contact my personal physician, local emergency notification system, or go to the nearest emergency room.
8. I understand that it is my duty to inform my provider of interactions regarding my care that I may have with other healthcare providers.
9. I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.
10. I have read and understand the information provided below, have discussed it with my provider or such assistants as may be designated, and all of my questions have been answered to my satisfaction.
11. I hereby give my informed consent for the care outlined below and, if applicable, the use of telemedicine in my medical care.
12. I have read and understand the General Terms and Conditions below and agree to the policies outlined in this document.

General Terms and Conditions

Our services may include, without limitation, psychotherapy and medication management and may be performed using telehealth as a treatment modality. For some people, in-person psychotherapy and medication management may be available. Providers may include primary care practitioners, masters-level and doctoral-level therapists, psychiatrists or other specialists.

Psychotherapy

Often called talk therapy, this form of treatment can be helpful to individuals. Benefits can include improved mood, improved relationships, and resolution of specific problems. However, therapy is not guaranteed to work for everybody. Psychotherapy may also require exploring unpleasant aspects of your life and can, at times, lead to feelings of distress (i.e., guilt, anxiety, frustration, etc.) or a temporary increase in symptoms. These unpleasant aspects are generally temporary but are important to discuss when present. Thus, it is important to let your therapist know if you feel that your goals aren’t being met. These issues can be addressed in sessions, which typically last 50 minutes. Occasionally, therapists need to discontinue therapy. Although this is rare, if therapy ends prematurely, a suitable referral or transition will be discussed with you.

Medication Management

Medications may be indicated when your symptoms are not responsive to psychotherapy alone. When a mental illness markedly impacts your ability to work, maintain interpersonal relationships, or properly care for your basic needs, medication may offer much-needed relief. Not everyone is a good candidate for medication treatment. Such treatment requires adherence to prescribed dosing frequency and close follow-up. Your ability to adhere to medication treatment will be taken into consideration in making the decision to start such treatment. Additionally, your physician will discuss the risks, benefits, side effects, government warnings, and alternative treatments (which always includes not using medications) with you to help you determine the best treatment options available for your specific needs. Current federal law does not allow tele-providers to prescribe controlled substances without an in-person visit. If your tele-provider determines you need this type of medication, you may be referred to your primary care provider with a recommendation to prescribe this medication

Limitations to Evaluation Types

Spring providers are not able to provide the following types of evaluations: a return to work fitness for duty evaluations, parental custody evaluations, court-mandated treatment, emotional support animal evaluations, weapons purchase clearance evaluations or other similar administrative evaluations. Patients may request a copy of their patient record or ask for a statement letter for attendance at sessions. This information will be sent directly to patients. Patients can share these records directly with any agency of their choice. Spring and associated providers will not send patient records directly to any third party that is not involved in your patient care.

Consent to In-Person Care

If in-person psychotherapy or medication management services are available to you, and you chose to engage in those services, you certify that a provider has explained the nature, benefits, and potential risks of those services, and that you have been given the opportunity to ask questions about any concerns regarding the services.

Telehealth as a Treatment Modality

Telehealth involves the use of audio, video and other electronic communications to enable health care providers to access individual patient medical information for the purpose of patient care. As part of this process, your provider may need to verify your identity as well as ask your location during a session to provide effective care. Details of your medical history and personal health information may be discussed with you or other health care professionals through the use of interactive video, audio, or other telecommunications technology. Some patients do not find distance counseling to be as intimate or helpful as traditional in-person counseling. Often times, this is because it is a new way of communicating. However, once patients have participated in a couple of sessions they find that they can benefit from using telehealth. If you decide telehealth is not for you, you should promptly notify your therapist or Spring Care Navigator so an alternative, more effective mode of treatment may be arranged (by Spring and/or a third-party provider).

Expected Benefits of Telehealth:

• Improved access to medical care by enabling a patient to obtain consultations from a wider range of healthcare practitioners at distant/other sites that are not available for in-person care
• More efficient medical evaluation and management with a wider range of appointment availability compared to only in-person care
• More convenient care scheduling and logistics

Possible Risks of Telehealth:

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

• In rare cases, information transmitted may not be sufficient (e.g. poor connectivity) to allow for appropriate medical decision making by care providers;
• Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment;
• In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information;
• In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors;
• In some cases, it may be difficult for providers to track your location and guide your care in emergency situations;
• In some cases, you may have multiple individuals involved with your care to determine the ideal plan of treatment; these individuals may be psychotherapists, physicians, medical administrators, and care navigator staff.

Electronic Information/Systems:

Electronic information collected during your sessions may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:

• Patient medical records and electronic/paper communications
• Live two-way audio and video
• Output data from sound and video files
• Messaging appointment reminders to your phone

Electronic systems used in your care 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.

Personal Health Information Data Management:

Spring follows all applicable HIPAA federal guidelines in protecting and managing your data. Under HIPAA, you have a right to get a copy of your medical record, correct your medical record, ask us to limit the information we share, receive a list of those with whom we have shared your information, get a copy of this privacy notice, choose some to act for you and file a complaint if you believe your privacy rights have been violated

Under HIPAA, Spring is allowed to share your data without your consent with business associates with an HIPAA agreement in place for the following reasons: to facilitate your treatment; run our organization; bill for your services; help with public health and safety issues; do research; comply with other laws; address workers compensation, law enforcement, and other government requests; and respond to lawsuits and legal actions.

For more information on management of your protected health information contact your care navigator.

Patient Responsibility/Missed Appointment Policy:

• Spring is not an enrolled Medicaid or Medicare provider. If Spring does not participate in your health care plan, you may be responsible for greater out-of-pocket expenses than you would for an in-network service. You may submit a request for an estimate of the amount that you will be billed for the out-of-network service. Please submit your request to https://www.springhealth.com/support

• All out-of-network costs (OON) and self-pay members are required to pay the full session price on the day of session. Invoices will be delivered via email. At the end of each month, you will receive a superbill to reflect all services rendered and payments made. You can then independently submit the superbill to your insurance or coinsurance carrier for any possible reimbursements under your insurance plan.
• If Spring participates in your health care plan, you will be required to pay the in-network deductible or co-pay, according to your plan, within 24 hrs of the service rendered. Invoices will be delivered via email.
• If your employer offers a number of no cost visits per calendar year, you will be responsible for payment for any additional visits beyond those no cost offerings. Your insurance may cover a portion of those costs, as noted in the in-network and out-of-network notes above.
• Any outstanding balance is subject to a finance charge of 3% after 60 days past due.
• I understand all appointments have to be confirmed by me in advance to retain my time slot.
• If I cancel a visit within 24 hours of a scheduled telehealth visit, then I am responsible for a cancellation processing fee of $50 (or I will have an employer-sponsored visit deducted).
• If I am over 10 mins late to a telehealth therapy visit, it is up to the provider’s discretion to cancel or shorten a visit. If canceled, then I may be responsible for a cancellation fee as above.

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CONSENTIMIENTO PARA SERVICIOS

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Este formulario describe las políticas de asesoramiento y sesión de Spring Health e incluye:

Su consentimiento para recibir asesoramiento de un proveedor afiliado a Spring Health; y

Su acuerdo para recibir servicios utilizando tecnología de telesalud.

Al marcar "Acepto el consentimiento de Spring para los servicios", usted acepta que ha leído y entendido lo siguiente:

1. Entiendo que tengo el derecho de retener o retirar mi consentimiento para el uso de los servicios de telesalud en el curso de mi atención en cualquier momento.
2. Entiendo que una variedad de métodos alternativos de atención pueden estar disponibles para mí.
3. Entiendo que, en caso de tener una emergencia médica, debo comunicarme inmediatamente con mi médico personal, el sistema local de notificación de emergencias o ir a la sala de emergencias más cercana.
4. Entiendo que es mi deber informar a mi proveedor de las interacciones con respecto a mi atención que pueda tener con mis proveedores de atención médica en la medida en que sean relevantes. 
5. He leído y entiendo la información proporcionada a continuación.
6. He leído las condiciones de la política de responsabilidad/citas perdidas del miembro de Spring Health y acepto las políticas que se describen en este documento.

SERVICIOS Y POLÍTICAS RELACIONADAS DE SPRING HEALTH

Los servicios se pueden realizar utilizando la telesalud como modalidad de tratamiento. Estos servicios serán proporcionados por terapeutas que son independientes de Spring Health, incluidos profesionales con calificaciones y/o registros en los organismos profesionales aplicables necesarios para proporcionar los servicios relevantes en su país, estado o localidad, y pueden incluir psicólogos, terapeutas, asesores u otros especialistas.

Spring Health no brinda por sí misma ningún servicio o tratamiento médico o de salud de ningún tipo. Este documento es solo para fines informativos y no debe interpretarse como un consejo médico. 

Limitaciones a los tipos de evaluación

Los proveedores de Spring Health no pueden proporcionar los siguientes tipos de evaluaciones: administración de medicamentos, reincorporación al trabajo para evaluaciones de servicio, evaluaciones de custodia de los padres, tratamiento ordenado por la corte, evaluaciones de animales de apoyo emocional u otras evaluaciones administrativas similares. Los miembros pueden solicitar una copia de su registro de miembro o solicitar una carta de declaración para asistir a las sesiones.  Los miembros pueden compartir estos registros directamente con cualquier agencia de su elección. Los proveedores no enviarán sus registros directamente a ningún tercero que no esté involucrado en su atención a menos que usted haya dado su autorización por escrito.

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La telesalud como modalidad de tratamiento

La telesalud implica el uso de audio, video y otras comunicaciones electrónicas para permitir a los proveedores acceder a la información individual de los Miembros con fines de atención. Como parte de este proceso, es posible que su proveedor deba verificar su identidad y solicitar su ubicación durante una sesión para brindar una atención efectiva. Los detalles de su información médica personal pueden analizarse con usted mediante el uso de video interactivo, audio u otra tecnología de telecomunicaciones. Algunos miembros no consideran que el asesoramiento a distancia sea tan íntimo o útil como el asesoramiento tradicional en persona. A menudo, esto se debe a que es una nueva forma de comunicarse. Sin embargo, muchos Miembros descubren que, después de haber participado en varias sesiones, pueden beneficiarse del uso de la telesalud. Si decide que la telesalud no es para usted, debe notificarlo de inmediato a su terapeuta o a un Care Navigator de Spring Health.

Beneficios esperados de la telesalud:: 

• mejorar el acceso a la atención al permitir que un Miembro obtenga consultas de una gama más amplia de proveedores en sitios distantes/otros que no están disponibles para la atención en persona;
• evaluación y gestión más eficientes con una gama más amplia de disponibilidad de citas en comparación con la atención solo en persona; y
• programación y logística de atención más convenientes.

Posibles riesgos de la telesalud: 

Al igual que con cualquier evaluación y tratamiento, existen riesgos potenciales asociados con el uso de la telesalud. Estos riesgos incluyen, entre otros:

• en casos excepcionales, la información transmitida puede no ser suficiente (p. ej., conectividad deficiente) para permitir la toma de decisiones adecuada por parte de los proveedores;
• retrasos en la evaluación y el tratamiento podrían ocurrir debido a deficiencias o fallas del equipo;
• en casos muy raros, los protocolos de seguridad podrían fallar, causando una violación de la privacidad de la información personal;
• en algunos casos, puede ser difícil para los proveedores rastrear su ubicación y guiar su atención en situaciones de emergencia; y
• En algunos casos, es posible que tenga varias personas involucradas en su atención para determinar el plan de tratamiento ideal.

Información/sistemas electrónicos:

La información electrónica recopilada por los proveedores durante sus sesiones se puede utilizar para asesoramiento, seguimiento y/o educación, y puede incluir cualquiera de los siguientes:

• Registros de miembros y comunicaciones electrónicas/en papel;
• audio y video bidireccional en vivo; y/o
• datos de salida de archivos de sonido y video.

Los sistemas electrónicos utilizados en su cuidado incorporarán protocolos de seguridad de red y software para proteger la confidencialidad de sus datos de identificación e imágenes e incluirán medidas para salvaguardar los datos y garantizar su integridad contra la corrupción intencional o no intencional.

Spring Health puede enviar recordatorios electrónicos de citas a su teléfono.

Información básica sobre Protección de datos y Gestión de datos personales de salud:

Spring Health utiliza, maneja y protege su información y datos personales de acuerdo con el Aviso de privacidad de Spring Health. Con su consentimiento, usted autoriza el procesamiento de sus datos personales para la correcta prestación del servicio de telesalud. En este sentido, Spring Health prevé la comunicación de sus datos a terceros y las transferencias internacionales de datos personales, con sujeción a las garantías adecuadas de conformidad con la legislación aplicable. Tiene derecho a acceder, rectificar y suprimir los datos, así como otros derechos, tal y como se explica en el citado Aviso de Privacidad. Póngase en contacto con su Care Navigator si tiene más preguntas.

Política de responsabilidad del miembro/cita perdida:

• Spring Health no es un proveedor inscrito en ningún plan de atención médica gubernamental o universal.
• Usted entiende que debe confirmar todas las citas con anticipación para conservar su franja horaria.
• Si cancela una cita dentro de las 24 horas posteriores a una cita programada de telesalud, entonces puede ser responsable de una tarifa de procesamiento de cancelación (o se le deducirá una cita patrocinada por el empleador).
• Si llega más de 10 minutos tarde a una cita de terapia de telesalud, queda a discreción del proveedor cancelar o acortar una cita. Si se cancela, es posible que tenga que pagar una tarifa de cancelación como la indicada anteriormente.

CONSENTIMIENTO DE LOS PADRES PARA EL TRATAMIENTO DE MENORES

Consentimiento para el tratamiento

Yo, el abajo firmante, soy el padre/madre/tutor legal del menor mencionado anteriormente y por este medio doy mi consentimiento para que mi hijo participe en el asesoramiento de salud mental proporcionado a través de Spring Care, Inc. (Spring Health).

Naturaleza del asesoramiento

‍

Entiendo que el asesoramiento de salud mental puede implicar hablar de asuntos que pueden ser delicados o difíciles para mi hijo. Pueden incluir relaciones familiares, experiencias escolares, crecimiento personal y bienestar emocional. El objetivo del asesoramiento es ayudar a mi hijo a desarrollar estrategias de afrontamiento, mejorar la regulación emocional y mejorar la salud mental en general.

‍

Confidencialidad

‍

Entiendo que la confidencialidad de las sesiones de asesoramiento de mi hijo está protegida por la ley. La información divulgada durante el asesoramiento no se compartirá con terceros sin mi consentimiento por escrito, salvo en los casos en que la ley exija su divulgación. Estas excepciones incluyen situaciones en las que existe un riesgo de daño a mi hijo u otras personas, sospecha de abuso infantil, o según lo requiera una orden judicial.

Límites del servicio

‍

Entiendo que el asesoramiento de salud mental no es una garantía de mejora y que los resultados pueden variar. Acepto que los servicios de asesoramiento no sustituyen la atención médica y que debo buscar asesoramiento médico si es necesario.

Autoridad de los padres

‍

Al establecer esta cuenta en nombre del menor, declaro que:

- Tengo el derecho legal exclusivo de dar mi consentimiento para el tratamiento de mi hijo, **O**

- He obtenido el consentimiento del otro progenitor/tutor legal para inscribir a mi hijo en el asesoramiento de salud mental.

Consentimiento y acuerdo

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Declaro que he leído, entendido y estoy de acuerdo con los términos descritos en este consentimiento de los padres, así como el consentimiento para el tratamiento. Doy voluntariamente mi consentimiento para que mi hijo participe en el asesoramiento de salud mental con Spring Health.

Si tiene alguna pregunta o duda sobre este formulario de consentimiento o el proceso de asesoramiento, no dude en comunicarse con careteam@springhealth.com

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 CONSENTIMIENTO PARA LA RECOPILACIÓN Y PROCESAMIENTO DE INFORMACIÓN DE SALUD

Este formulario describe la recopilación y el procesamiento por parte de Spring Health de sus datos de salud proporcionados mediante una combinación de su uso de nuestros servicios, incluida la interacción con nuestros sitios web, aplicaciones móviles, proveedores de salud mental, equipo de atención y/o sus respuestas al Cuestionario de Spring Health relacionado con su salud física y/o mental (“información de salud”). 

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Al hacer clic en Aceptar, da su consentimiento explícito para la recopilación y el procesamiento de su Información de salud  y acepta y entiende que:

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1. Su información de salud se utilizará para brindarle los servicios.

2. Su equipo de atención, incluidos todos los proveedores de Spring Health que le brindan servicios, Care Navigators y representantes de apoyo a la atención, tendrán acceso a su información de salud. 

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3. Su información de salud se utilizará para nuestra gestión interna y con fines comerciales, como el análisis de datos, el desarrollo de nuevos servicios, la mejora o modificación de los servicios y la identificación de tendencias de uso.

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4. Su información de salud se utilizará para auditorías, control de fraudes y prevención.

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5. El procesamiento de su información de salud puede incluir la divulgación de información estadística anónima y agregada a su empleador y/u otros terceros por parte de Spring Health.

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6. Si participa en un programa de recompensas, su información de salud se utilizará para activar sus recompensas. 

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7. Su información de salud se utilizará para la facturación, el pago y las reclamaciones.

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8. Su información de salud se transferirá y procesará en Estados Unidos.

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Usted comprende que la información médica es información confidencial y que no está obligado a dar su consentimiento para este procesamiento. Si no da su consentimiento, es posible que no pueda acceder a ciertos servicios ofrecidos por Spring Health. Usted entiende que puede ejercer sus derechos a (i) acceder a su información personal, (ii) rectificar/borrar su información personal, (iii) restringir el procesamiento de su información personal y (iv) retirar su consentimiento para procesar su información personal.

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Más información sobre el procesamiento de su Información de salud, incluida la información sobre los derechos disponibles para usted, se establece en el Aviso de Privacidad de Spring Health .

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Puede retirar su consentimiento enviando un correo electrónico a privacy@springhealth.com 

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This form describes Spring Health’s treatment and payment policies for children under 18 and includes:Your consent on behalf of the patient to receive mental health treatment from Spring Health or a Spring Health affiliated provider;Your agreement on behalf of the minor patient to receive services using telehealth technology, as applicable; andYour agreement to pay in full any charges that are your responsibility You represent that you are the patient’s parent or legal guardian and are duly authorized under state law to act on behalf of the minor. All references to “you” or “I” shall be deemed to include the minor patient where such reference applies to the individual receiving care.

By typing your name and clicking “I agree to the Terms of Service” on the Spring Health website, you agree on behalf of the minor patient:

1. I understand that the laws that protect the privacy and the confidentiality of medical information also apply to telemedicine and that no information obtained in the use of telemedicine which identifies me will be disclosed to other non-covered entities without my consent.
2. I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.
3. Subject to applicable law, I understand that I have the right to inspect medical information obtained and recorded in the course of a provider visit, and may receive copies of this information for a reasonable fee.
4. I understand that 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.
5. I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.
6. I understand that I may need to provide photo-identification and my physical location to allow for accurate and effective care to be delivered.
7. I understand that if I am having a medical emergency that I should immediately contact my personal physician, local emergency notification system, or go to the nearest emergency room.
8. I understand that it is my duty to inform my provider of interactions regarding my care that I may have with other healthcare providers.
9. I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.
10. I have read and understand the information provided below, have discussed it with my provider or such assistants as may be designated, and all of my questions have been answered to my satisfaction.
11. I hereby give my informed consent for the care outlined below and, if applicable, the use of telemedicine in my medical care.
12. I have read and understand the General Terms and Conditions below and agree to the policies outlined in this document.

General Terms and Conditions

Our services may include, without limitation, psychotherapy and medication management and may be performed using telehealth as a treatment modality. For some people, in-person psychotherapy and medication management may be available. Providers may include primary care practitioners, masters-level and doctoral-level therapists, psychiatrists or other specialists.

Psychotherapy

Often called talk therapy, this form of treatment can be helpful to individuals. Benefits can include improved mood, improved relationships, and resolution of specific problems. However, therapy is not guaranteed to work for everybody. Psychotherapy may also require exploring unpleasant aspects of your life and can, at times, lead to feelings of distress (i.e., guilt, anxiety, frustration, etc.) or a temporary increase in symptoms. These unpleasant aspects are generally temporary but are important to discuss when present. Thus, it is important to let your therapist know if you feel that your goals aren’t being met. These issues can be addressed in sessions, which typically last 50 minutes. Occasionally, therapists need to discontinue therapy. Although this is rare, if therapy ends prematurely, a suitable referral or transition will be discussed with you.

Medication Management

Medications may be indicated when your symptoms are not responsive to psychotherapy alone. When a mental illness markedly impacts your ability to work, maintain interpersonal relationships, or properly care for your basic needs, medication may offer much-needed relief. Not everyone is a good candidate for medication treatment. Such treatment requires adherence to prescribed dosing frequency and close follow-up. Your ability to adhere to medication treatment will be taken into consideration in making the decision to start such treatment. Additionally, your physician will discuss the risks, benefits, side effects, government warnings, and alternative treatments (which always includes not using medications) with you to help you determine the best treatment options available for your specific needs. Current federal law does not allow tele-providers to prescribe controlled substances without an in-person visit. If your tele-provider determines you need this type of medication, you may be referred to your primary care provider with a recommendation to prescribe this medication

Limitations to Evaluation Types

Spring providers are not able to provide the following types of evaluations: a return to work fitness for duty evaluations, parental custody evaluations, court-mandated treatment, emotional support animal evaluations, weapons purchase clearance evaluations or other similar administrative evaluations. Patients may request a copy of their patient record or ask for a statement letter for attendance at sessions. This information will be sent directly to patients. Patients can share these records directly with any agency of their choice. Spring and associated providers will not send patient records directly to any third party that is not involved in your patient care.

Consent to In-Person Care

If in-person psychotherapy or medication management services are available to you, and you chose to engage in those services, you certify that a provider has explained the nature, benefits, and potential risks of those services, and that you have been given the opportunity to ask questions about any concerns regarding the services.

Telehealth as a Treatment Modality

Telehealth involves the use of audio, video and other electronic communications to enable health care providers to access individual patient medical information for the purpose of patient care. As part of this process, your provider may need to verify your identity as well as ask your location during a session to provide effective care. Details of your medical history and personal health information may be discussed with you or other health care professionals through the use of interactive video, audio, or other telecommunications technology. Some patients do not find distance counseling to be as intimate or helpful as traditional in-person counseling. Often times, this is because it is a new way of communicating. However, once patients have participated in a couple of sessions they find that they can benefit from using telehealth. If you decide telehealth is not for you, you should promptly notify your therapist or Spring Care Navigator so an alternative, more effective mode of treatment may be arranged (by Spring and/or a third-party provider).

Expected Benefits of Telehealth:

• Improved access to medical care by enabling a patient to obtain consultations from a wider range of healthcare practitioners at distant/other sites that are not available for in-person care
• More efficient medical evaluation and management with a wider range of appointment availability compared to only in-person care
• More convenient care scheduling and logistics

Possible Risks of Telehealth:

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

• In rare cases, information transmitted may not be sufficient (e.g. poor connectivity) to allow for appropriate medical decision making by care providers;
• Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment;
• In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information;
• In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors;
• In some cases, it may be difficult for providers to track your location and guide your care in emergency situations;
• In some cases, you may have multiple individuals involved with your care to determine the ideal plan of treatment; these individuals may be psychotherapists, physicians, medical administrators, and care navigator staff.

Electronic Information/Systems:

Electronic information collected during your sessions may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:

• Patient medical records and electronic/paper communications
• Live two-way audio and video
• Output data from sound and video files
• Messaging appointment reminders to your phone

Electronic systems used in your care 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.

Personal Health Information Data Management:

Spring follows all applicable HIPAA federal guidelines in protecting and managing your data. Under HIPAA, you have a right to get a copy of your medical record, correct your medical record, ask us to limit the information we share, receive a list of those with whom we have shared your information, get a copy of this privacy notice, choose some to act for you and file a complaint if you believe your privacy rights have been violated

Under HIPAA, Spring is allowed to share your data without your consent with business associates with an HIPAA agreement in place for the following reasons: to facilitate your treatment; run our organization; bill for your services; help with public health and safety issues; do research; comply with other laws; address workers compensation, law enforcement, and other government requests; and respond to lawsuits and legal actions.

For more information on management of your protected health information contact your care navigator.

Patient Responsibility/Missed Appointment Policy:

• Spring is not an enrolled Medicaid or Medicare provider. If Spring does not participate in your health care plan, you may be responsible for greater out-of-pocket expenses than you would for an in-network service. You may submit a request for an estimate of the amount that you will be billed for the out-of-network service. Please submit your request to https://www.springhealth.com/support

• All out-of-network costs (OON) and self-pay members are required to pay the full session price on the day of session. Invoices will be delivered via email. At the end of each month, you will receive a superbill to reflect all services rendered and payments made. You can then independently submit the superbill to your insurance or coinsurance carrier for any possible reimbursements under your insurance plan.
• If Spring participates in your health care plan, you will be required to pay the in-network deductible or co-pay, according to your plan, within 24 hrs of the service rendered. Invoices will be delivered via email.
• If your employer offers a number of no cost visits per calendar year, you will be responsible for payment for any additional visits beyond those no cost offerings. Your insurance may cover a portion of those costs, as noted in the in-network and out-of-network notes above.
• Any outstanding balance is subject to a finance charge of 3% after 60 days past due.
• I understand all appointments have to be confirmed by me in advance to retain my time slot.
• If I cancel a visit within 24 hours of a scheduled telehealth visit, then I am responsible for a cancellation processing fee of $50 (or I will have an employer-sponsored visit deducted).
• If I am over 10 mins late to a telehealth therapy visit, it is up to the provider’s discretion to cancel or shorten a visit. If canceled, then I may be responsible for a cancellation fee as above.

‍

‍

This form describes Spring Health’s treatment and payment policies for children under 18 and includes:Your consent on behalf of the patient to receive mental health treatment from Spring Health or a Spring Health affiliated provider;Your agreement on behalf of the minor patient to receive services using telehealth technology, as applicable; andYour agreement to pay in full any charges that are your responsibility You represent that you are the patient’s parent or legal guardian and are duly authorized under state law to act on behalf of the minor. All references to “you” or “I” shall be deemed to include the minor patient where such reference applies to the individual receiving care.

By typing your name and clicking “I agree to the Terms of Service” on the Spring Health website, you agree on behalf of the minor patient:

1. I understand that the laws that protect the privacy and the confidentiality of medical information also apply to telemedicine and that no information obtained in the use of telemedicine which identifies me will be disclosed to other non-covered entities without my consent.
2. I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.
3. Subject to applicable law, I understand that I have the right to inspect medical information obtained and recorded in the course of a provider visit, and may receive copies of this information for a reasonable fee.
4. I understand that 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.
5. I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.
6. I understand that I may need to provide photo-identification and my physical location to allow for accurate and effective care to be delivered.
7. I understand that if I am having a medical emergency that I should immediately contact my personal physician, local emergency notification system, or go to the nearest emergency room.
8. I understand that it is my duty to inform my provider of interactions regarding my care that I may have with other healthcare providers.
9. I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.
10. I have read and understand the information provided below, have discussed it with my provider or such assistants as may be designated, and all of my questions have been answered to my satisfaction.
11. I hereby give my informed consent for the care outlined below and, if applicable, the use of telemedicine in my medical care.
12. I have read and understand the General Terms and Conditions below and agree to the policies outlined in this document.

General Terms and Conditions

Our services may include, without limitation, psychotherapy and medication management and may be performed using telehealth as a treatment modality. For some people, in-person psychotherapy and medication management may be available. Providers may include primary care practitioners, masters-level and doctoral-level therapists, psychiatrists or other specialists.

Psychotherapy

Often called talk therapy, this form of treatment can be helpful to individuals. Benefits can include improved mood, improved relationships, and resolution of specific problems. However, therapy is not guaranteed to work for everybody. Psychotherapy may also require exploring unpleasant aspects of your life and can, at times, lead to feelings of distress (i.e., guilt, anxiety, frustration, etc.) or a temporary increase in symptoms. These unpleasant aspects are generally temporary but are important to discuss when present. Thus, it is important to let your therapist know if you feel that your goals aren’t being met. These issues can be addressed in sessions, which typically last 50 minutes. Occasionally, therapists need to discontinue therapy. Although this is rare, if therapy ends prematurely, a suitable referral or transition will be discussed with you.

Medication Management

Medications may be indicated when your symptoms are not responsive to psychotherapy alone. When a mental illness markedly impacts your ability to work, maintain interpersonal relationships, or properly care for your basic needs, medication may offer much-needed relief. Not everyone is a good candidate for medication treatment. Such treatment requires adherence to prescribed dosing frequency and close follow-up. Your ability to adhere to medication treatment will be taken into consideration in making the decision to start such treatment. Additionally, your physician will discuss the risks, benefits, side effects, government warnings, and alternative treatments (which always includes not using medications) with you to help you determine the best treatment options available for your specific needs. Current federal law does not allow tele-providers to prescribe controlled substances without an in-person visit. If your tele-provider determines you need this type of medication, you may be referred to your primary care provider with a recommendation to prescribe this medication

Limitations to Evaluation Types

Spring providers are not able to provide the following types of evaluations: a return to work fitness for duty evaluations, parental custody evaluations, court-mandated treatment, emotional support animal evaluations, weapons purchase clearance evaluations or other similar administrative evaluations. Patients may request a copy of their patient record or ask for a statement letter for attendance at sessions. This information will be sent directly to patients. Patients can share these records directly with any agency of their choice. Spring and associated providers will not send patient records directly to any third party that is not involved in your patient care.

Consent to In-Person Care

If in-person psychotherapy or medication management services are available to you, and you chose to engage in those services, you certify that a provider has explained the nature, benefits, and potential risks of those services, and that you have been given the opportunity to ask questions about any concerns regarding the services.

Telehealth as a Treatment Modality

Telehealth involves the use of audio, video and other electronic communications to enable health care providers to access individual patient medical information for the purpose of patient care. As part of this process, your provider may need to verify your identity as well as ask your location during a session to provide effective care. Details of your medical history and personal health information may be discussed with you or other health care professionals through the use of interactive video, audio, or other telecommunications technology. Some patients do not find distance counseling to be as intimate or helpful as traditional in-person counseling. Often times, this is because it is a new way of communicating. However, once patients have participated in a couple of sessions they find that they can benefit from using telehealth. If you decide telehealth is not for you, you should promptly notify your therapist or Spring Care Navigator so an alternative, more effective mode of treatment may be arranged (by Spring and/or a third-party provider).

Expected Benefits of Telehealth:

• Improved access to medical care by enabling a patient to obtain consultations from a wider range of healthcare practitioners at distant/other sites that are not available for in-person care
• More efficient medical evaluation and management with a wider range of appointment availability compared to only in-person care
• More convenient care scheduling and logistics

Possible Risks of Telehealth:

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

• In rare cases, information transmitted may not be sufficient (e.g. poor connectivity) to allow for appropriate medical decision making by care providers;
• Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment;
• In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information;
• In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors;
• In some cases, it may be difficult for providers to track your location and guide your care in emergency situations;
• In some cases, you may have multiple individuals involved with your care to determine the ideal plan of treatment; these individuals may be psychotherapists, physicians, medical administrators, and care navigator staff.

Electronic Information/Systems:

Electronic information collected during your sessions may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:

• Patient medical records and electronic/paper communications
• Live two-way audio and video
• Output data from sound and video files
• Messaging appointment reminders to your phone

Electronic systems used in your care 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.

Personal Health Information Data Management:

Spring follows all applicable HIPAA federal guidelines in protecting and managing your data. Under HIPAA, you have a right to get a copy of your medical record, correct your medical record, ask us to limit the information we share, receive a list of those with whom we have shared your information, get a copy of this privacy notice, choose some to act for you and file a complaint if you believe your privacy rights have been violated

Under HIPAA, Spring is allowed to share your data without your consent with business associates with an HIPAA agreement in place for the following reasons: to facilitate your treatment; run our organization; bill for your services; help with public health and safety issues; do research; comply with other laws; address workers compensation, law enforcement, and other government requests; and respond to lawsuits and legal actions.

For more information on management of your protected health information contact your care navigator.

Patient Responsibility/Missed Appointment Policy:

• Spring is not an enrolled Medicaid or Medicare provider. If Spring does not participate in your health care plan, you may be responsible for greater out-of-pocket expenses than you would for an in-network service. You may submit a request for an estimate of the amount that you will be billed for the out-of-network service. Please submit your request to https://www.springhealth.com/support

• All out-of-network costs (OON) and self-pay members are required to pay the full session price on the day of session. Invoices will be delivered via email. At the end of each month, you will receive a superbill to reflect all services rendered and payments made. You can then independently submit the superbill to your insurance or coinsurance carrier for any possible reimbursements under your insurance plan.
• If Spring participates in your health care plan, you will be required to pay the in-network deductible or co-pay, according to your plan, within 24 hrs of the service rendered. Invoices will be delivered via email.
• If your employer offers a number of no cost visits per calendar year, you will be responsible for payment for any additional visits beyond those no cost offerings. Your insurance may cover a portion of those costs, as noted in the in-network and out-of-network notes above.
• Any outstanding balance is subject to a finance charge of 3% after 60 days past due.
• I understand all appointments have to be confirmed by me in advance to retain my time slot.
• If I cancel a visit within 24 hours of a scheduled telehealth visit, then I am responsible for a cancellation processing fee of $50 (or I will have an employer-sponsored visit deducted).
• If I am over 10 mins late to a telehealth therapy visit, it is up to the provider’s discretion to cancel or shorten a visit. If canceled, then I may be responsible for a cancellation fee as above.

‍

‍

This form describes Spring Health’s treatment and payment policies for children under 18 and includes:Your consent on behalf of the patient to receive mental health treatment from Spring Health or a Spring Health affiliated provider;Your agreement on behalf of the minor patient to receive services using telehealth technology, as applicable; andYour agreement to pay in full any charges that are your responsibility You represent that you are the patient’s parent or legal guardian and are duly authorized under state law to act on behalf of the minor. All references to “you” or “I” shall be deemed to include the minor patient where such reference applies to the individual receiving care.

By typing your name and clicking “I agree to the Terms of Service” on the Spring Health website, you agree on behalf of the minor patient:

1. I understand that the laws that protect the privacy and the confidentiality of medical information also apply to telemedicine and that no information obtained in the use of telemedicine which identifies me will be disclosed to other non-covered entities without my consent.
2. I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.
3. Subject to applicable law, I understand that I have the right to inspect medical information obtained and recorded in the course of a provider visit, and may receive copies of this information for a reasonable fee.
4. I understand that 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.
5. I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.
6. I understand that I may need to provide photo-identification and my physical location to allow for accurate and effective care to be delivered.
7. I understand that if I am having a medical emergency that I should immediately contact my personal physician, local emergency notification system, or go to the nearest emergency room.
8. I understand that it is my duty to inform my provider of interactions regarding my care that I may have with other healthcare providers.
9. I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.
10. I have read and understand the information provided below, have discussed it with my provider or such assistants as may be designated, and all of my questions have been answered to my satisfaction.
11. I hereby give my informed consent for the care outlined below and, if applicable, the use of telemedicine in my medical care.
12. I have read and understand the General Terms and Conditions below and agree to the policies outlined in this document.

General Terms and Conditions

Our services may include, without limitation, psychotherapy and medication management and may be performed using telehealth as a treatment modality. For some people, in-person psychotherapy and medication management may be available. Providers may include primary care practitioners, masters-level and doctoral-level therapists, psychiatrists or other specialists.

Psychotherapy

Often called talk therapy, this form of treatment can be helpful to individuals. Benefits can include improved mood, improved relationships, and resolution of specific problems. However, therapy is not guaranteed to work for everybody. Psychotherapy may also require exploring unpleasant aspects of your life and can, at times, lead to feelings of distress (i.e., guilt, anxiety, frustration, etc.) or a temporary increase in symptoms. These unpleasant aspects are generally temporary but are important to discuss when present. Thus, it is important to let your therapist know if you feel that your goals aren’t being met. These issues can be addressed in sessions, which typically last 50 minutes. Occasionally, therapists need to discontinue therapy. Although this is rare, if therapy ends prematurely, a suitable referral or transition will be discussed with you.

Medication Management

Medications may be indicated when your symptoms are not responsive to psychotherapy alone. When a mental illness markedly impacts your ability to work, maintain interpersonal relationships, or properly care for your basic needs, medication may offer much-needed relief. Not everyone is a good candidate for medication treatment. Such treatment requires adherence to prescribed dosing frequency and close follow-up. Your ability to adhere to medication treatment will be taken into consideration in making the decision to start such treatment. Additionally, your physician will discuss the risks, benefits, side effects, government warnings, and alternative treatments (which always includes not using medications) with you to help you determine the best treatment options available for your specific needs. Current federal law does not allow tele-providers to prescribe controlled substances without an in-person visit. If your tele-provider determines you need this type of medication, you may be referred to your primary care provider with a recommendation to prescribe this medication

Limitations to Evaluation Types

Spring providers are not able to provide the following types of evaluations: a return to work fitness for duty evaluations, parental custody evaluations, court-mandated treatment, emotional support animal evaluations, weapons purchase clearance evaluations or other similar administrative evaluations. Patients may request a copy of their patient record or ask for a statement letter for attendance at sessions. This information will be sent directly to patients. Patients can share these records directly with any agency of their choice. Spring and associated providers will not send patient records directly to any third party that is not involved in your patient care.

Consent to In-Person Care

If in-person psychotherapy or medication management services are available to you, and you chose to engage in those services, you certify that a provider has explained the nature, benefits, and potential risks of those services, and that you have been given the opportunity to ask questions about any concerns regarding the services.

Telehealth as a Treatment Modality

Telehealth involves the use of audio, video and other electronic communications to enable health care providers to access individual patient medical information for the purpose of patient care. As part of this process, your provider may need to verify your identity as well as ask your location during a session to provide effective care. Details of your medical history and personal health information may be discussed with you or other health care professionals through the use of interactive video, audio, or other telecommunications technology. Some patients do not find distance counseling to be as intimate or helpful as traditional in-person counseling. Often times, this is because it is a new way of communicating. However, once patients have participated in a couple of sessions they find that they can benefit from using telehealth. If you decide telehealth is not for you, you should promptly notify your therapist or Spring Care Navigator so an alternative, more effective mode of treatment may be arranged (by Spring and/or a third-party provider).

Expected Benefits of Telehealth:

• Improved access to medical care by enabling a patient to obtain consultations from a wider range of healthcare practitioners at distant/other sites that are not available for in-person care
• More efficient medical evaluation and management with a wider range of appointment availability compared to only in-person care
• More convenient care scheduling and logistics

Possible Risks of Telehealth:

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

• In rare cases, information transmitted may not be sufficient (e.g. poor connectivity) to allow for appropriate medical decision making by care providers;
• Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment;
• In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information;
• In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors;
• In some cases, it may be difficult for providers to track your location and guide your care in emergency situations;
• In some cases, you may have multiple individuals involved with your care to determine the ideal plan of treatment; these individuals may be psychotherapists, physicians, medical administrators, and care navigator staff.

Electronic Information/Systems:

Electronic information collected during your sessions may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:

• Patient medical records and electronic/paper communications
• Live two-way audio and video
• Output data from sound and video files
• Messaging appointment reminders to your phone

Electronic systems used in your care 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.

Personal Health Information Data Management:

Spring follows all applicable HIPAA federal guidelines in protecting and managing your data. Under HIPAA, you have a right to get a copy of your medical record, correct your medical record, ask us to limit the information we share, receive a list of those with whom we have shared your information, get a copy of this privacy notice, choose some to act for you and file a complaint if you believe your privacy rights have been violated

Under HIPAA, Spring is allowed to share your data without your consent with business associates with an HIPAA agreement in place for the following reasons: to facilitate your treatment; run our organization; bill for your services; help with public health and safety issues; do research; comply with other laws; address workers compensation, law enforcement, and other government requests; and respond to lawsuits and legal actions.

For more information on management of your protected health information contact your care navigator.

Patient Responsibility/Missed Appointment Policy:

• Spring is not an enrolled Medicaid or Medicare provider. If Spring does not participate in your health care plan, you may be responsible for greater out-of-pocket expenses than you would for an in-network service. You may submit a request for an estimate of the amount that you will be billed for the out-of-network service. Please submit your request to https://www.springhealth.com/support

• All out-of-network costs (OON) and self-pay members are required to pay the full session price on the day of session. Invoices will be delivered via email. At the end of each month, you will receive a superbill to reflect all services rendered and payments made. You can then independently submit the superbill to your insurance or coinsurance carrier for any possible reimbursements under your insurance plan.
• If Spring participates in your health care plan, you will be required to pay the in-network deductible or co-pay, according to your plan, within 24 hrs of the service rendered. Invoices will be delivered via email.
• If your employer offers a number of no cost visits per calendar year, you will be responsible for payment for any additional visits beyond those no cost offerings. Your insurance may cover a portion of those costs, as noted in the in-network and out-of-network notes above.
• Any outstanding balance is subject to a finance charge of 3% after 60 days past due.
• I understand all appointments have to be confirmed by me in advance to retain my time slot.
• If I cancel a visit within 24 hours of a scheduled telehealth visit, then I am responsible for a cancellation processing fee of $50 (or I will have an employer-sponsored visit deducted).
• If I am over 10 mins late to a telehealth therapy visit, it is up to the provider’s discretion to cancel or shorten a visit. If canceled, then I may be responsible for a cancellation fee as above.

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服务同意书

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本同意书旨在介绍 Spring Health 的咨询和预约政策，其中包括：

您同意接受 Spring Health 关联提供商提供的咨询服务；以及

您同意通过远程医疗技术接受服务。

勾选“我同意 Spring 的服务同意书”，即表示您确认已阅读并知悉以下内容：

1. 我知悉，我有权在接受照护的过程中随时拒绝或撤回对使用远程医疗服务的同意。
2. 我知悉，有多种替代照护方法可供选择。
3. 我知悉，如果遇到医疗紧急情况，我应立即联系私人医生、拨打当地急救电话或前往最近的急诊室。
4. 我知悉，我有责任将与其他医疗保健提供商在照护过程中进行的相关互动告知当前提供商。 
5. 我已阅读并知悉下述信息。
6. 我已阅读 Spring Health 会员（下称“会员”）责任/错过预约政策，并同意本同意书中概述的政策。

Spring Health 服务及相关政策

Spring Health 可能通过远程医疗治疗模式来提供服务。 相关服务将由与 Spring Health 无隶属关系的治疗师提供，这些专业人士具有在您所在国家、州或地区提供相关服务所需的资质，并且/或者已向相关专业机构登记，可能包括心理学家、治疗师、咨询师或其他专家。

Spring Health 本身不提供医疗或保健服务，也不提供任何形式的治疗。 本文件仅供参考，不应视为医疗建议。 

评估类型的限制

Spring Health 提供商无法提供以下类型的评估：药物管理评估、重返工作岗位适任性评估、父母监护权评估、法院强制治疗评估、情感支持型动物评估或其他类似的行政评估。 会员可以要求获取其会员记录副本或要求出具出席预约的说明信，  还可以直接与所选机构分享这些记录。 除非您给予书面授权，否则提供商不会将您的记录直接发送给未参与照护的第三方。

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远程医疗治疗模式

远程医疗是指采用音频、视频和其他电子通信方式，确保提供商能够访问会员信息以提供照护服务。 在此过程中，提供商可能需要验证您的身份并询问您当前所在位置，以提供有效的照护。 提供商可能会通过互动视频、音频或其他电信技术与您讨论您的个人健康详细信息。 部分会员认为远程咨询不如传统的面对面咨询效果好，缺乏亲密感。 通常，这是因为远程医疗是一种新的沟通方式。 但是，在参加几次咨询后，许多会员发现，他们可以从远程医疗中受益。 如果您认为远程医疗不适合您，请立即通知您的治疗师或 Spring Health Care Navigator。

远程医疗的预期好处： 

• 确保会员能够向更多无法提供面对面照护的远程/其他地点的提供商咨询，提高其获得照护的机会；
• 与仅提供面对面照护相比，可以提供更广泛的预约时间选择，从而提升评估和管理的效率；
• 更便捷的照护安排和就医流程。

远程医疗的潜在风险： 

与其他评估和治疗一样，使用远程医疗也存在潜在风险， 包括但可能不限于：

• 在少数情况下（例如连接不畅），传输的信息可能不足以让提供商做出适当的决策；
• 因设备缺陷或故障而延误评估和治疗；
• 在极少数情况下，安全协议可能会失效，导致个人信息隐私泄露；
• 在某些情况下，提供商可能难以追踪您的位置，无法在紧急情况下为您的照护提供指导；
• 在某些情况下，可能会有多位人员参与您的照护，以确定理想的治疗计划。

电子信息/系统：

提供商在与您互动过程中可能收集以下电子信息，并将其用于咨询、随访和/或知识普及：

• 会员记录和电子/纸质通信；
• 实时双向音频和视频；和/或
• 音频和视频文件的输出数据。

在您的照护过程中使用的电子系统将采用网络和软件安全协议，以保护您的身份和影像数据的机密性，同时还将采取相关措施，以保障数据安全并确保其完整性不受有意或无意损坏。

Spring Health 可能会向您的手机发送电子预约提醒。

有关数据保护和个人健康信息数据管理的基本信息：

Spring Health 将根据其隐私声明使用、处理和保护您的个人信息和数据。 我们会在经您同意并获得您授权的情况下处理您的个人数据，以确保正常提供远程医疗服务。 在提供远程医疗服务的过程中，Spring Health 会依据适用法律，采取适当的保障措施，将您的数据传输给第三方或其他国家/地区。 如上述隐私声明所述，您享有数据访问权、更正权、删除权等权利。 如有任何其他问题，请联系您的 Care Navigator。

会员责任/错过预约政策：

• Spring Health 不是任何政府或全民医疗保健计划的注册提供商。
• 您知悉，为保留预约时段，必须提前确认预约。
• 如果在离远程医疗预约时间不到 24 小时的情况下取消预约，可能需要支付取消手续费（或扣除一次雇主赞助的预约机会）。
• 如果您在远程医疗预约中迟到超过 10 分钟，提供商可自行决定取消或缩短预约。 如果取消，您可能需要支付如上所述的取消费用。

家长同意书（适用于未成年人治疗）

治疗同意书

我（即下方签字人）是上述未成年人的家长/法定监护人，特此同意我的孩子接受通过 Spring Care, Inc.（下称“Spring Health”）提供的心理健康咨询服务。

咨询服务的性质

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我知悉，在心理健康咨询过程中，可能会讨论一些对我的孩子来说较为敏感或棘手的话题， 比如家庭关系、学校经历、个人成长和情绪健康。 咨询服务旨在帮助我的孩子培养应对策略、改善情绪调节能力，并增强整体心理健康。

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保密

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我知悉，我孩子所接受的咨询会严格保密，受法律保护。 未经我的书面同意，咨询过程中披露的信息绝不会与他人分享，法律规定必须披露的情况 （比如我的孩子或他人面临受伤害的风险、涉嫌虐待儿童，或法院命令要求披露）除外。

服务局限性

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我知悉，心理健康咨询并不能保证一定有效，效果因人而异。 我知晓，咨询服务不能替代医疗照护，必要时我应寻求专业医疗建议。

家长授权声明

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我以未成年子女的名义创建此账户，即声明并保证：

- 我是唯一有法律权利同意我孩子接受治疗的人；**或者**

- 我已获得另一位家长/法定监护人的同意，让我的孩子接受心理健康咨询服务。

同意与协议

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我确认我已阅读、理解并同意本《家长同意书》及《治疗同意书》中列出的所有条款。 我自愿同意我的孩子接受由 Spring Health 提供的心理健康咨询服务。

如果您对本同意书或咨询流程有任何疑问或顾虑，请随时发邮件至 careteam@springhealth.com 联系我们。

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 健康信息收集和处理同意书

本同意书旨在介绍 Spring Health 如何收集和处理您在使用我们服务（包括访问我们的网站、使用我们的移动应用程序、与心理健康提供商或照护团队互动以及/或者您对 Spring Health 问卷中关于您身心健康状况问题的回答）过程中提供的健康数据（下称“健康信息”）。 

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点击“同意”，即表示您明确同意我们收集和处理您的健康信息，并同意和知悉以下内容：

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1. 您的健康信息将用于为您提供服务。

2. 照护团队（包括所有为您提供服务的 Spring Health 提供商、Care Navigator 和照护支持代表）可以访问您的健康信息。

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3. 您的健康信息将用于我们的内部管理和业务目的，如分析数据；开发新服务；提升、改进或调整服务；确定使用趋势。

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4. 您的健康信息将用于审计以及欺诈监测和预防。

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5. 处理您的健康信息时，Spring Health 可能会向您的雇主和/或其他第三方披露经匿名化和汇总处理的统计信息。

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6. 如果您参与奖励计划，您的健康信息将用于激活奖励。 

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7. 您的健康信息将用于账单处理、付款及理赔事宜。

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8. 您的健康信息将传输到美国并在美国处理。

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您知悉，健康信息属于敏感信息，您并没有义务同意我们处理您的健康信息。 如果不同意，您可能无法访问 Spring Health 提供的某些服务。 您知悉，您可以行使以下权利：(i) 访问您的个人信息；(ii) 更正/删除您的个人信息；(iii) 限制对您个人信息的处理；以及 (iv) 撤回对处理您个人信息的同意。

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有关我们如何处理您健康信息的更多信息，包括您所享权利的信息，请参阅 Spring Health 隐私声明。

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如需撤回同意，请发送邮件至 privacy@springhealth.com 

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