I understand that by checking “I Agree” I give my informed consent to the rendering of professional mental health care services via the UpLift Health Technologies, Inc. (“UpLift”) platform, which includes, without limitation, receiving remote care via telephone, video or other electronic means, including asynchronous technology, by the mental health care providers that treat me through the UpLift platform including, but not limited to, providers that are employed by or contracted with UpLift Behavioral Health PC and UpLift Behavioral Health NJ, PC (collectively the “Behavioral Health Professional Entities”) or in-person care at the office of one of the Behavioral Health Professional Entities mental health care providers (“Behavioral Health Locations”). Care may include, but is not limited to, assessing, diagnosing, and treating a wide range of mental health illnesses with professional mental health services and other follow-up care (which may include prescribing medications), as needed.

For telehealth treatment, I understand that using the UpLift platform sometimes involves the delivery of mental health services by a provider that is located at a different site by using electronic information and communication technologies. Electronic communication technologies, including audio, video, and/or data communications may be used between the patient and the mental health care provider to transmit data including, but not limited to, personal health information, photographs, videos, prescriptions/orders and medical records. I understand that the remote services may be provided by new technologies not included in this consent. I will be informed of all parties that are present during a remote service.

I understand that a mental health care provider has the right to determine that my needs are not appropriate for remote treatment and, as a result, I may need to seek alternative treatment methods (e.g., such as receiving in-person care with one of the Behavioral Health Locations).  Receiving remote treatment is voluntary and if I decide to stop receiving remote treatment, that will not impact my right to receive mental health care services in the future.

For treatment by telehealth or in-person, I understand that the laws that protect privacy and confidentiality of my medical information also apply to the services I receive via the UpLift platform and at Behavioral Health Locations. I understand that any information shared in any therapy process is confidential and may not be shared without prior consent, except in certain circumstances such as suspected abuse, threat to self or others, or as required by law.

I understand that mental healthcare, including but not limited to the practices of psychiatry, psychology and mental health counseling, is  not an exact science and that diagnosis and treatment involves benefits and risks. There may be risks to my physical or mental well-being.

If I elect to receive remote services, I understand that there are specific risks and benefits to receiving services remotely.

Benefits of remote services include the following:  

• Remote care is more accessible and allows you to receive care without the wait and at a time and place that is convenient for you.
• Remote care can improve communication between you and your provider.
• Remote care is subject to the same privacy protections as in-person visits.

Risks of remote services include the following:

• A remote mental health care exam is not a complete exam and does not allow for physical assessment and in some cases could lead to an incorrect diagnosis or be insufficient for a provider affiliated with UpLift to perform services for you.
• The transmission of protected health information via the internet could result in a data breach, subjecting your health information to exposure.
• Technological glitches can disrupt internet connections and cause a delay to your session with the provider.

WARNING

Do not use this service if you are experiencing a medical emergency, if you are thinking about suicide or are considering actions that may cause harm to you or others, or if your current healthcare provider has advised against your participation. Regardless of whether you receive telehealth services or in-person care, in the event of an emergency, call 911 or a crisis hotline or proceed to the nearest emergency room. This is not an emergency service.

Services provided via the UpLift platform or at Behavioral Health Locations are not intended to replace your primary care medical services. The UpLift platform and the Behavioral Health Locations do not provide crisis services to the general public, or mental health services for individuals under the age of 13.

Costs and Reimbursements

I will receive information regarding fees including expectations for payment, insurance information and cancellation fees.

Patient Acknowledgment and Agreement

I hereby acknowledge that I am aware of all potential risks associated with receiving services from UpLift, including any remote mental health care services, and mental health care services at the Behavioral Health Locations. I acknowledge that no guarantees have been made to me regarding the result of a diagnosis or treatment provided to me by providers affiliated with UpLift. As with any other health care and/or mental health services, some individuals do not respond to treatment.

I have disclosed all relevant background and history, any known health conditions that my mental health care provider has requested I disclose in advance of receiving services and, if applicable, allergies and medications I am taking, including herbal medications/supplements.

I authorize the UpLift affiliated provider to share information pertaining to my treatment (including any remote treatment) with other individuals for treatment, payment and health care operations purposes including, without limitation, my primary care provider. I authorize any affiliated provider(s) to release information pertaining to my remote treatment to UpLift and its affiliates.

I understand that the terms herein are contractual and not a mere recital and that I electronically sign this document as my own free act and void of any coercion.  The permissions granted herein shall begin on the date listed below and shall remain effective until terminated by me. I understand that I have the right to withhold or withdraw my consent at any time by submitting a request via email to info@joinuplift.co.

If I am a patient residing in Virginia, I agree to hold harmless Uplift and its affiliates for information lost due to any technical failure of the UpLift platform.  

I understand that clicking “I Agree” constitutes a legal signature and verifies that I that I have read all of the information contained in this Consent Form, I understand the risks and benefits of receiving services (including remote services) by providers affiliated with the UpLift platform and the Behavioral Health Locations and the ability to withdraw treatment at any time (and understand the possible risks associated with withdrawing) and I have had an opportunity to ask questions about anything I have not understood up to this point.

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

This Notice of Privacy Practices describes how we may use and disclose your protected health information and your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition, and related health care services. We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice at any time. The new notice will be effective for all protected health information that we maintain at that time. It will be available upon request and on our website.

This Notice of Privacy Practices shall apply to the following entities, collectively referred to as “UpLift”: Uplift Health Technologies, Inc.; Uplift Behavioral Health, P.C.; Shine Medical, P.C.; Shine Medical Providers, P.C.; Shine Medical of CA, P.C. and Shine Medical of NJ, P.C. Each entity is a “Covered Entity”.

1. Uses and Disclosures of Protected Health Information

Following are examples of the types of uses and disclosures of your protected health information that the Covered Entity is permitted to make. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that we may make.

Treatment

We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination of your health care with another provider. For example, we would disclose your protected health information, as necessary, to a physician or hospital that provides care to you.

Payment

Your protected health information will be used and disclosed, as needed, to obtain payment for your health care services provided by us or by another provider. This may include responses to inquiries regarding invoices for the health care services we provide.

Health Care Operations

We may use or disclose your protected health information in order to support our business activities, including for quality assessment, employee review, training, and conducting or arranging for other business activities. We also may share your protected health information with third-party “business associates” that perform various activities for us. We will have a written contract with business associates to protect the privacy of your protected health information. We may use or disclose your protected health information, as necessary, to provide you with information about our services or other health-related benefits and services that may be of interest to you; you may contact our Privacy Officer to opt out of receiving these materials.

Other Permitted and Required Uses and Disclosures That May Be Made Without Your Authorization or Opportunity to Agree or Object  

These situations include:

Required by Law: We may use or disclose your protected health information to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. 

Public Health: We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. For example, a disclosure may be made for the purpose of preventing or controlling disease.

Communicable Diseases: We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.

‍Health Oversight: We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws. 

Abuse or Neglect: We may disclose your protected health information if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.

Food and Drug Administration: We may disclose your protected health information to a person or company required by the Food and Drug Administration for the purpose of quality, safety, or effectiveness of FDA-regulated products or activities including, to report adverse events, product defects or problems, biologic product deviations, or to track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required. 

Legal Proceedings: We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), or in certain conditions in response to a subpoena, discovery request or other lawful process. 

Law Enforcement: We may also disclose protected health information, so long as applicable legal requirements are met, for law enforcement purposes. 

Coroners, Funeral Directors, and Organ Donation: We may disclose protected health information to a coroner, medical examiner or funeral director to assist them in performing their legally-authorized duties. 

Research: We may disclose your protected health information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.

Criminal Activity: Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual. 

Military Activity and National Security: When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services. We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized. 

Workers’ Compensation: We may disclose your protected health information as authorized to comply with workers’ compensation laws and other similar legally-established programs.

‍Minors: We may share a minor’s health information with the minor’s parents or guardians unless such disclosure is prohibited by state or federal law.

Uses and Disclosures of Protected Health Information Based upon Your Written Authorization

Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below. For example, uses or disclosures for certain marketing activities or that constitute a sale of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law. You may revoke any authorization in writing at any time. If you revoke your authorization, we will no longer use or disclose your protected health information for the reasons covered by your written authorization. Please understand that we are unable to take back any disclosures that you previously authorized.

Other Permitted and Required Uses and Disclosures That Require Providing You the Opportunity to Agree or Object

Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person’s involvement in your health care, if any. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care. If you are not present or able to agree or object to the use or disclosure of the protected health information, then your caregiver may, using professional judgment, determine whether the disclosure is in your best interest.

Other Legal Requirements

State and federal laws may provide additional protection of some of your protected health information. For example, we may need to obtain your authorization or a court order to disclose certain sensitive information, such as information regarding mental health or substance use disorder treatment. We also may need to obtain your permission to disclose protected health information to certain state-sponsored registries.

2. Your Rights: Following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights.

You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of protected health information about you. You may access or obtain your records, including medical and billing records and any other records that the Covered Entity uses for making decisions about you. As permitted by federal and state law, we may charge you a reasonable copy fee for a copy of your records. If legally permitted, the Covered Entity may deny access to certain information, including information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding. In some circumstances, you may have a right to have this decision reviewed. Please contact our Privacy Officer if you have questions about access to your medical record.

You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment, or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes. We are not required to agree to a restriction except if you request to restrict disclosure of your protected health information to a health plan, if (i) the disclosure is for payment or other health care operations purposes and is not otherwise required by law and (ii) the information pertains solely to a health care item or service for which you paid the Covered Entity in full. If the Covered Entity does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. You may request a restriction by contacting our Privacy Officer.

You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. Please make this request in writing to our Privacy Officer.

You may have the right to request an amendment of your protected health information. In certain cases, we may deny your request for an amendment and you will have the right to file a statement of disagreement with us. We may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact our Privacy Officer about amending your medical record.  

You have the right to receive an accounting of certain disclosures we have made of your protected health information. This right applies to disclosures for purposes other than treatment, payment or health care operations as described in this Notice of Privacy Practices. It excludes disclosures we may have made to you if you authorized us to make the disclosure, to family members or friends involved in your care, or for notification purposes, for national security or intelligence, to law enforcement or correctional facilities, or as part of a limited data set disclosure. The right to receive this information is subject to certain exceptions, restrictions, and limitations.

You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically.

You have the right to be notified of a breach of unsecured protected health information that affects you.

‍

3. Complaints

You may complain to us or to the Department of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with the Department at www.hhs.gov/ocr/privacy/hipaa/complaints and with us by notifying our Privacy Officer via phone (888) 380-2028, email at julian@joinuplift.co, or in writing at PO Box 360721 Pittsburgh, PA 15251-6721. We will not retaliate against you for filing a complaint.

I understand that by signing this Patient Financial Responsibility Agreement, I consent to the terms and conditions set forth below regarding the professional therapy services I receive from providers using the UpLift Health Technologies, Inc. and UpLift Behavioral Health PC (“UpLift”) platform.

I acknowledge and agree as follows:

• I assume full responsibility, and agree to pay all costs, charges, co-payments and expenses of every kind and description for all services provided to me by UpLift and my provider using the UpLift platform.
  

• Each bill for any charges from UpLift or the providers using the UpLift platform will be due upon completion of your session.
• UpLift reserves the right to deactivate my account after nonpayment of 3 sessions and/or late cancel fees.
  

• UpLift accepts most major credit cards and payments via ACH.
  

• If I have a health insurance policy, I have carefully read the section in my health insurance policy that describes mental health services.  If I have questions about my coverage, I will call the plan administrator to ask questions and clarify my benefits. I am responsible for knowing what my insurance plan will and will not cover.
  

• If I have a health insurance policy, I have provided UpLift with the most correct and updated information about my insurance. If I provide UpLift with incorrect information about my insurance, I will be fully responsible for any charges for the cost of my therapy services provided through the UpLift platform.
  

• I may incur additional charges at the discretion of UpLift, including without limitation charges for credit card payment processing fees, missed appointments without notice per UpLift’s policies, charges for extensive phone consultations and/or after-hours calls, and any costs associated with the collection of my unpaid balances.
  

• I authorize UpLift and the providers using the UpLift platform to release my medical and other information acquired in the course of my examination and/or treatment to the necessary insurance companies, other third party payors, and/or other physicians or healthcare entities required to participate in my care.
  

• I authorize assignment of financial benefits directly to UpLift and the providers using the UpLift platform for any services rendered as allowable under standard insurance and other third-party payor contracts.  I understand I am financially responsible for charges not covered by this assignment.
  

I understand that the terms herein are contractual and not a mere recital and that I sign this document as my own free act and void of any coercion.

I understand that clicking “I Agree” constitutes a legal signature and verifies that I have read all of the information contained in this Patient Financial Responsibility Agreement.

Patient Rights & Responsibilities

The Program is reviewed annually by the UpLift Health Technologies, Inc. Quality Assurance (QA) Program and updated as necessary to assure that all Patients of UpLift are informed of their rights and that such rights are respected throughout the process of service delivery.  

Quality Assurance Committee

UpLift Health Technologies, Inc. (“UpLift”) maintains a Quality Assurance (“Program”) to fulfill the UpLift clinical oversight responsibilities.  The Chairperson of the committee is responsible for the oversight and operation of the UpLift QA Program  The Committee must review and approve the policies each year.  The Committee is a peer-review body that includes participating Providers and Clinical Leadership.  

Core Indicators and Goals

• Safety of Patients
• Quality of Care
• Quality Improvement
• Performance Improvement
• Access to Care
• Patient Satisfaction
• Provider Satisfaction          

Commitment to Patient Rights  

‍All patients requesting services from UpLift have a right to receive such services without regard to race, ethnicity, age, color, religion, creed, gender, national origin, sexual orientation, veteran status, financial condition, handicap, or disability. No distinction will be formulated in determining eligibility for participation in services provided by UpLift based on any of these identifiers, conditions, or circumstances.

All individuals requesting services from UpLift shall receive this statement of Patient Rights as part of the intake and initial orientation process, and, if appropriate, on an annual basis. Said statement shall conform to all applicable regulations issued by State, Federal, and other funders; and shall include, but not be limited to:

Patient Rights

• The right to select a professional counselor or psychiatry provider who meets your needs.
• The right to obtain a copy of the code(s) of ethics your provider must follow.
• The right to receive specific information about your provider’s qualifications, education, expertise, certifications, and state licensure.
• The right to be informed of one’s condition, proposed or current services, treatment, therapies, and alternatives.
• ​​The right to consent to or refuse any service, treatment, or therapy upon full explanation of the expected consequences of such consent or refusal.
• The right to receive a written explanation of services offered, time commitments, fee scales, and billing policies before receiving services.
• The right to a current, written, individualized treatment plan that addresses one’s mental health, physical health, social and economic needs, and that specifies the provision of appropriate and adequate services, as available, either directly or by referral.
• The right to active and informed participation in the establishment, periodic review, and reassessment of the treatment plan.
• The right to be treated with consideration and respect for personal dignity, autonomy, and privacy.
• The right to receive culturally competent care, and to be treated with respect, consideration, and dignity.
• The right to ask questions about confidentiality and its limits as specified in state laws and professional ethical codes.
• The right to receive information about emergency procedures (e.g., how to contact your provider in the event of a crisis).
• The right to ask questions to your provider about counseling techniques & strategies, including potential risks & benefits.
• The right to establish goals and evaluate treatment progress with your provider.
• The right to request additional opinions from other mental health assessment professionals.
• The right to understand the implications of the diagnosis and the intended use of treatment documentation.
• The right to be informed in advance of the reason(s) for discontinuance of service provision, and to be involved in planning for transitioning your care.
• The right to receive an explanation of the reasons for denial of service.
• The right to terminate the counseling or psychiatry relationship at any time.
• The right to share any concerns or complaints you may have regarding a professional provider’s conduct with UpLift, the appropriate professional organization, or the licensure board.
• The right to exercise any rights without reprisal in any form including continued and uncompromised access to service.
• The right to obtain copies of medical records.
• The right to have oral and written instructions for filing a grievance.  
• The right to file a grievance with UpLift.
• The right to investigation and resolution of an alleged infringement of rights.
• The right to receive prompt, respectful, and courteous communication from UpLift.

Patient Responsibilities

For your counselor, psychiatrist, or nurse practitioner to provide the highest quality of services, it is important that patients:

• Inform your provider if you are receiving mental health services from another professional.
• Adhere to established appointment schedules.
• Follow agreed-upon goals and strategies established in sessions.
• Inform your provider of your progress and challenges in meeting your goals.
• Participate fully in each session to help maximize a positive outcome.
• Consider appropriate referrals to additional support from your provider.
• If you must miss an appointment, contact your provider as soon as possible.
• Avoid placing your provider in ethical dilemmas, such as requesting to become involved in social interactions or bartering for services.
• Pay your bill in accordance with the billing agreements.
  

Video Recording

Video recordings of patient consultations are not permitted. The consultations are considered the same as if the patient attended counseling or psychiatry services at the provider’s office.  

Non-Retaliation Policy

UpLift will not take any disciplinary action or other types of retaliation against any patient, contractor, or employee who, in good faith, reports a concern, issue, or management problem to help@joinuplift.co.