All clinical services are provided by Flourish Health Medical Practice, LLC or other professional service entities to which Flourish Health, Inc. provides administrative services. Flourish Health Medical Practice LLC and such professional service entities are collectively referred to herein as, "Flourish Health," and together with Flourish Health, Inc. are hereinafter to as "Flourish". Adolescents and young adults receiving mental health care from Flourish Health shall be referred to herein as, "Patient."
This agreement ("Agreement") is intended to provide you with important information regarding the practices, policies and procedures of Flourish. Please read the entire document carefully and ask any questions before signing the document. Please initial each section to indicate that you have read and understood that particular section.
I consent to treatment and care provided by Flourish Health. I also consent to care by physicians, therapists and other team members authorized by Flourish Health. I understand that my treatment and care may include multiple services such as supportive text-based conversation, therapy sessions, medication management, laboratory testing, advocacy at school, exercise, and other services. I understand that there are no guarantees about the results of my treatment and care.
I understand I have the right to refuse any procedure or treatment while in Flourish Health's care. I understand I have the right to discuss all medical and behavioral treatments with my care team.
I consent to telehealth visits as part of my care. Flourish Health and their providers may contact me by telephone or electronic mail to communicate with me.
I consent to in person visits as part of my care. Flourish Health and their providers may visit my residence address and coordinate to meet with me at other locations as part of my care.
I consent to collect my blood pressure, heart rate and other vital signs as directed by my care team. I agree to communicate with them honestly about the findings. I understand that Flourish Health is not treating me for general medicine conditions and will not be able to provide emergency services or general medicine guidance if my vital signs are abnormal.
I understand that I may be offered a fitbit as part of my treatment. I agree to take care of the fitbit. I understand I am expected to return the fitbit at the end of my participation in Flourish Health's program.
I understand that part of my treatment and care may be support or accommodations in school. I understand that Flourish Health might help me and my family advocate for appropriate support accommodations in school. I consent to my treatment team contacting my school and communicating about my needs.
I understand that Flourish Health's program is not a substitute for emergency medical services or hospitalization. I understand that if I have a medical or psychiatric emergency, that I should call 911 or go to my nearest emergency room.
I understand that information I tell one patient of my treatment team will be shared with the rest of my treatment team. I give permission to Flourish Health providers to share information about me with each other. I understand this is usually done so that my care team can collaborate and provide me with the best treatment and care possible.
I have given my social security number voluntarily. Flourish Health may use it for accurate identification, filing insurance claims and compliance with federal and state laws.
I understand that my care team may be required or permitted to break confidentiality when they have determined that I am in serious risk of danger either to myself, or to another person. I understand that my care team may also have to break confidentiality if someone is hurting me.
Flourish Health is HIPAA compliant. Please indicate that you have received and signed the document named "Notice of Privacy Practices." This document further explains how your medical information will be used by this practice.
I give permission for Flourish Health and their providers to release information about me, my health, my treatment, or payment of my treatment as permitted by law.
I understand that this program is designed to be 12 months. I understand that I am only eligible for as long as I have my current health insurance. I understand that Flourish Health reserves the right to end my treatment early.
Questions or Complaints: If you have any questions about this informed consent form, please contact Flourish by emailing info@flourish.health.
1\\. I understand that Flourish Health will use telemedicine in the course of my diagnosis and treatment.
2\\. I understand that the laws that protect the privacy and 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 researchers or other entities without my consent.
3\\. I understand that upon my consent, my telemedicine interactions may be recorded and used for quality and training purposes, and to advance and optimize the telemedicine program.
4\\. 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. However, given that Flourish Health is a telemedicine treatment program, I understand that by withholding or withdrawing my consent, I also thereby terminate my Flourish Health treatment. In order to withdraw my consent, I must notify info@flourish.health of my desire to withdraw my consent. However, I understand that any action already taken in reliance on this consent prior to my revocation cannot be reversed.
5\\. I understand that I have the right to inspect all information obtained and recorded in the course of a telemedicine interaction subject to applicable law, and may receive copies of this information for a reasonable fee.
6\\. 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. My care team has explained the alternatives to my satisfaction.
7\\. 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.
8\\. I understand that it is my duty to inform my care team 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 Flourish Health's services in my care, but that no results can be guaranteed or assured.
1. I understand that Flourish Health is not acting as my primary medical provider. I agree that I will seek medical advice, care and treatment from my primary physician or other qualified health care provider if I have any questions or concerns, or if my health condition warrants. I further agree that I will not disregard any professional medical advice or delay seeking medical treatment from my primary physician or other qualified health care provider as a result of any advice or treatment received from Flourish Health.
2. I acknowledge that I have been informed with respect to the purpose, possible benefits, risks and limitations in connection with therapy treatment and I have received a copy of this consent form. I acknowledge that I have been given the opportunity to ask questions regarding my therapy treatment, and my questions have been answered to my satisfaction.`,