Informed Consent Policy

Last updated: August 11th, 2024

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DO NOT USE THIS SERVICE IF YOU MAY BE EXPERIENCING A MEDICAL EMERGENCY. In an emergent situation, you can: (i) call 911; (ii) go to the nearest emergency room; (iii) contact your local crisis center; (iv) if applicable, call the National Suicide Prevention Lifeline (1-800-272-8255); or (v) if applicable, contact the Crisis Text Line (text “GO” to 741-741).

We are pleased you have chosen Agave Health, for your tele-behavioral health needs. This consent form is intended to inform you of what you can expect of your mental health clinician in terms of his or her credentials and in connection with your treatment via telehealth. After you have carefully read this document and had an opportunity to have your questions answered, certain state laws mandate that you must sign and date it before commencing services.

YOUR CLINICIAN’S CREDENTIALS. Your mental health clinician’s credentials were made available to you before scheduling an appointment. If you have any questions about these credentials, please direct them to your mental health clinician.

IMPORTANT INFORMATION REGARDING YOUR TREATMENT BY TELE-BEHAVIORAL HEALTH PROVIDERS, INCLUDING POTENTIAL RISKS AND BENEFITS. Agave Health offers individual, scheduled counseling sessions by means of tele-behavioral health. This simply means treatment by mental health coaches and clinicians via telecommunications technology. Our mental health clinicians include skilled and experienced Licensed Professional Counselors, Licensed Clinical Social Workers, Licensed Therapists, and equivalent licensed professionals. They each use a collaborative treatment process wherein they work with you on identified goals for overall improvement and changes you deem important or necessary to improve the quality of your life.

Generally speaking, tele-behavioral health offers benefits such as improved access to care by enabling patients to remain in their local site (e.g., home or work) while their clinician consults at distant/other sites, efficient mental health evaluation and management, and the expertise of specialists that patients otherwise might not have. There are potential risks associated with tele-behavioral health, which include, but may not be limited to: the clinician may determine that the transmitted information is of inadequate quality, thus necessitating a face-to-face meeting with the patient; delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment; security protocols could fail, causing a breach of privacy of personal medical information; lack of access to complete medical records, which could result in judgment errors in rare cases; and, it may become clear that tele-behavioral health is not an appropriate treatment format given a patient’s presenting symptoms or level of functioning, resulting in a recommendation that the patient obtain an additional in-person care.

At times, your clinician may seek supervision or consultation with other Agave Health clinicians regarding your treatment, to enhance the services being provided to you given the multiple perspectives, experiences, and treatment philosophies. All team members are ethically and legally bound to maintain your privacy and confidentiality in this scenario and none of your personal information will be shared or disclosed with any other individual without your consent. Exceptions to confidentiality do exist in certain situations, such as: threat of serious harm to self or others; reasonable suspicion of abuse or neglect of a child, or abuse, neglect, or exploitation of an incapacitated or dependent adult; court order and/or subpoena; permission from the client or guardian (i.e. voluntary release signed by the client or guardian); during supervisory consultations; diagnosis and dates of service shared with an insurance company to collect payments; information released as outlined Agave Health’s Notice of Privacy Practices and Privacy Policy; and as otherwise required by law.

TREATMENT AND CONFIDENTIALITY OF MINORS. In accordance with state laws, consent for treatment of a minor can only be authorized by a current legal guardian for the minor. If the parents of a minor are separated, treatment is provided to the minor only with the written consent of both parents. If the parents of the minor are divorced, consent for treatment of the minor may be given by the parent authorized to make medical decisions for the minor. If a court of law has ordered that medical decisions for the minor are to be made jointly by the minor’s parents, then consent of both parents is required for treatment of the minor. In the case of minors, as defined by state law, parents may request information about their child’s diagnosis or treatment. While release of this information will be provided, it is best that the process be a collaborative one involving the minor, parent, and clinician in order to maintain the rapport established between the minor and clinician since rapport is vital to treatment success. Therefore, unless there is a safety concern, the minor would be consulted about the disclosure and encouraged to share the information with the parent first in order to establish better communications within the family structure.

SCHEDULING AND CANCELLATIONS. Please carefully review the following Scheduling and Cancellations Policy: sessions with your therapist are booked on the Agave Health app ; cancellations and rescheduling can happen without any penalty up to 48 hours prior to the originally scheduled time of the session. Late cancellations will be charged a penalty up to the cost of the session. In case of emergency cancellations, please reach out to your therapist through your direct chat channel on the Agave Health app, so the therapist can elect to forego the penalty. By signing this document, you are attesting that you have read, understood and will comply with this Scheduling and Cancellations Policy.

FEES AND BILLING ARRANGEMENTS. Prices are subject to change. You will be charged the fees for your telehealth services upon completion of each session ; however, you are not obligated to pay any fees for which another party (e.g., your employer or health plan) pays on your behalf. If you believe any of the fees you have been charged are incorrect, you must immediately contact us in writing at hello@agavehealth.com regarding the amount in question to be eligible to receive a refund. You irrevocably waive your right to challenge the accuracy of any charge, or otherwise receive a refund, if you fail to notify us in writing within fifteen (15) calendar days after the charge, that you believe the charge is inaccurate (setting forth an explanation of why).

You also hereby authorize the direct payment of all insurance and plan benefits, including Medicare, Medicaid and/or Tricare, otherwise payable to or on your behalf for services rendered, to Agave Health. If you receive payment directly from your insurance company or third-party payer, you agree to immediately forward all healthcare payments that you receive for services provided to you.

By checking the box associated with “Informed Consent”, you acknowledge that you understand and agree with the following:
 

1. You hereby consent to receiving Agave Health’s services via telehealth technologies. You understand that Agave Health and its providers offer telehealth-based medical and coaching services, but that these services do not replace the relationship between you and your primary care doctor. You also understand it is up to the Agave Health provider or coach to determine whether or not your specific clinical needs are appropriate for a telehealth encounter.

2. You have been given an opportunity to select a provider from Agave Health prior to the consult, including a review of the provider’s credentials.

3. You understand that federal and state law requires health care providers to protect the privacy and the security of health information. You understand that Agave Health will take steps to make sure that your health information is not seen by anyone who should not see it. You understand that telehealth may involve electronic communication of your personal medical information to other health practitioners who may be located in other areas, including out of state.

4. You understand there is a risk of technical failures during the telehealth encounter beyond the control of Agave Health. You agree to hold harmless Agave Health for delays in evaluation or for information lost due to such technical failures.

5. You understand that you have the right to withhold or withdraw your consent to the use of telehealth in the course of your care at any time, without affecting your right to future care or treatment. You understand that you may suspend or terminate use of the telehealth services at any time for any reason or for no reason. You understand that if you are experiencing a medical emergency, that you will be directed to dial 9-1-1 immediately and that the Agave Health providers are not able to connect you directly to any local emergency services.

6. You understand that you may expect the anticipated benefits from the use of telehealth in your care, but that no results can be guaranteed or assured.

7. You understand that your healthcare information may be shared with other individuals for scheduling and billing purposes.

8. You understand that if you participate in a consultation, that you have the right to request a copy of your medical records.

 

You have read this document carefully, and understand the risks and benefits of the telehealth services and have had your questions regarding the services explained and you hereby give your informed consent to participate in a telehealth consultation under the terms described herein.

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By checking the Box for this “INFORMED CONSENT FOR TELEHEALTH SERVICES” inside the Agave Health app, you thereby state that you have read, understood, and agree to the terms of the policy.