1. SERVICES. Client acknowledges that he/she will be utilizing the professional telehealth services of BREAKTHROUGH COUNSELING SERVICES, and that one or more of the items below may not necessarily apply to such services. "Telehealth" services are those professional services that are provided through real-time, interactive, two-way communication technology or store-and-forward technologies, and which may include some or all of consultation, evaluation, diagnosis, treatment, transfer of medical data, and/or education, and the communication of medical and/or mental health information. This Agreement applies to any Telehealth service provided by or through BCS, and any remote interaction with any professional service contractor and any employee or any agent of BCS. The acceptance of such services by Client shall constitute acceptance of this Agreement. If you do not agree to all of the terms of this Agreement, then BCS is unwilling to provide any services to you.
IMPORTANT NOTICE: TELEHEALTH SERVICES ARE NOT FOR EMERGENCIES. IF YOU HAVE AN EMERGENCY, CALL 911 OR YOUR LOCAL EMERGENCY SERVICE. IF YOU ARE HAVING SUICIDAL THOUGHTS OR MAKING PLANS TO HARM YOURSELF, YOU MAY CALL THE NATIONAL SUICIDE PREVENTION LIFELINE AT 1-800-273-TALK (8255) FOR FREE 24 HOUR HOTLINE SUPPORT.
From time to time during the term of this Agreement, Client may request that BCS provide certain Telehealth services to Client through licensed professional providers who are independent contractors of BCS and who have or will have access to the Client's medical history and/or record (the "
"). BCS shall not be required to provide or otherwise coordinate any live or in-person, face-to-face services to the Client.
Client acknowledges and agrees that Client is solely responsible to ensure that the environment where Client is located during any Telehealth session is sufficiently private as to ensure that no personal or confidential information is relayed to any third party other than the BCS professional. At no time will BCS be responsible for i) any information that is disclosed, or ii) any other damages suffered by Client, due to the condition or location of the environment where Client is located during any Telehealth session. Client shall be responsible for the full cost of the applicable session if any interruption or stoppage occurs due to Client's actions, technological limitations of Client's equipment, or the environment where the Client is located, including without limitation weather-related and telecommunications equipment failure. BCS requires Client to have, and Client represents and warrants that he or she has, a video-conference camera and screen, and broadband capacity capable of an encrypted signal.
Client acknowledges and agrees that the Services are not a substitute for assistance or help required in an emergency or crisis situation. As such, Client agrees that any such emergency or crisis situation will be handled by the appropriate emergency personel by calling the appropriate emergency response telephone number, including without limitation dialing 911. At no time will BCS be responsible for any costs for, arising out of, or related to any emergency or crisis assistance.
Client acknowledges and agrees that Client is solely responsible for any personal injury Client may suffer due to any physical activity in which the Client engages during the provision of the Services.
Client acknowledges and accepts the possible limitations of Telehealth services as compared to in-person services for example, technical limitations which may affect the transmission of nuances of communication, such as tone of voice or non-verbal communications like body language, facial expression, or emotional cues. Client understands and accepts sole responsibility for Client's level of comfort with and willingness to accept Telehealth services.
2. PAYMENT FOR SERVICES.
(a) Client acknowledges and agrees that the total amounts charged hereunder are due when the Services are rendered. Client agrees that the rates for the Services have been identified clearly by a representative of BCS before Client accepts any Services. Client shall provide a current, valid credit card with sufficient credit to provide payment to BCS. Client is financially responsible for missed appointments. Client agrees that if Client does not provide at least twenty-four (24) hours' notice (by telephone only) of any appointment cancellation, BCS may charge Client's credit card a missed-appointment fee of seventy-five dollars ($75.00).
(b) Client acknowledges and assumes the responsibility to inform BCS if Client is involved in the legal system. BCS does not offer professional expert services and notes the possible limitations of Telehealth services for court-involved roles of BCS service providers. In the event of the required attendance of any BCS professional at any legal proceeding, in-court or out-of-court, Client agrees to pay BCS the rate of two hundred dollars ($200.00) per hour. Client agrees that the hourly rate applies to portal-to-portal travel time and includes any waiting time. Client agrees that a minimum fee representing two (2) hours ($400.00) shall be paid prior to any attendance at any legal proceeding and is non-refundable even if less than two (2) hours is expended by the professional. If the legal proceeding exceeds two (2) hours, Client agrees that BCS may charge the Client's credit card for the additional time. In addition, Client understands and agrees that Client is not paying for any specific opinion or testimony from the applicable professional, but rather for the professional's time. Therefore, such fees must be paid regardless of the content of the professional's testimony or opinion, and whether or not testimony is taken.
(c) Client understands and agrees and that Client is financially responsible for all charges for any and all Services rendered by or through BCS. Any payments not received at the time Services are rendered shall be subject to an interest charge of one and one half percent (1.5%) per month until paid in full. In the event BCS utilizes the services of any attorney or collection agent to collect any overdue balances, Client shall pay to BCS all costs of collection, including without limitation reasonable attorneys' fees and court costs.
(d) Please call our office at (240) 986-1001 to provide credit card information to be kept on file prior to your first appointment.
3. CONSENT. I do hereby consent to and authorize the performance of the Services deemed advisable by the applicable professional service provider. I understand that professional advice may be delayed, distorted, or rendered innacurate due to technology-related issues such as poor connectivity or image or sound quality. Additionally, I consent to authorize and release to my professional service provider all healthcare information relating to testing, diagnosis, and/or treatment for HIV, sexually transmitted diseases, psychiatric disorder/mental health issues, and/or drug and/or alcohol abuse. I understand that the terms of this Agreement and my consent will continue until cancelled by me in writing in accordance with the terms here of. Video conferences may not be recorded by either party without written consent. I acknowledge and understand that I may send and receive appointment and other administrative information about the Services by email or phone, but that text/SMS and unencrypted email messaging are not HIPAA Security Rule compliant. Therefore, I acknowledge and agree to utilize such secure messaging application(s) as may be requested or required by BCS from time to time to communicate individually identifiable health information ("Protected Health Information") related to the Services.
4. PROPRIETARY TECHNOLOGY. I acknowledge that technology utilized by BCS is or may be the intellectual property of BCS or its contracting parties, partners or affiliates, and if so, may be protected by US and international copyright laws, and may be covered by US Patents as well as additional international patents, or pending US or international patent applications.
5. PRESCRIPTION POLICY. BCS maintains a network of independent contractor licensed professional service providers, including licensed professionals providing telepsychiatry, who may offer prescriptions at their discretion. There is no guarantee that a prescription will be issued on any telepsychiatry consultation and prescriptions will only be issued if the licensed professional provider is able to gather the appropriate information to accurately diagnose and treat a given condition. Licensed professional providers will refer patients to their primary care physician or appropriate level of care when indicated.
6. RELATIONSHIP OF THE PARTIES; ENTIRE AGREEMENT. No agency relationship is created by this agreement, by the contemplated Services, or by the contemplated means of transmission utilized in the rendering Services. BCS has no responsibility for the existence, content, or any other characteristics of such software, hardware, or connections, or for the content of any communications between Client and the licensed professional providers or any other person, regardless of whether BCS provides, specifies, or directs the particular software, hardware, or means of transmission used to make such a connection, or otherwise facilitates the provision of Services hereunder. This Agreement contains the entire agreement of the parties, and their are no other promises or conditions in any other agreement whether oral or written.
7. SEVERABILITY. If any provision of this Agreement shall be held to be invalid or unenforcable for any reason, the remaining provision shall continue to be valid and enforceable if a court finds that any provision of this Agreement is invalid or unenforcable, but that by limiting such provision it would become valid and enforceable, then such provision shall be deemed to be written, construed, and enforced as so limited.
8. MISCELLANEOUS. This Agreement shall be binding upon and insure to the benefit of the parties and their respective successors, heirs, and permitted assigns. This Agreement may not be amended or modified except in a writing signed by both parties. This Agreement may not be assigned by either party without the express written consent of the other, which assignment without such written consent shall be void. This Agreement may be executed in one or more counterparts, each of which shall be deemed to be an original, but all of which together shall constitute one and the same document. Any facsimile, telecopy, email of a PDF file, or similar electronic conveyance of an original signature shall be deemed an original signature and bind the parties. This Agreement shall be governed and construed under the laws of the State of Maryland without reference to its conflict of laws principles. Neither party shall be liable for delays caused by fire, accident, labor dispute, war, insurrection, terrorism, riot, act of government, act of God, or any other cause reasonably beyond its control, but each party shall use all reasonable efforts to minimize the extent of such a delay.
IN WITNESS WHEREOF, the parties hereto have duly executed and delivered the Agreement as of the Effective Date.