Consent for Medication Management Care and Other Participation Terms

This document contains important information about the professional services and business policies of both your Lyra Clinical Associates P.C. (LCA) physician, and Lyra Clinical Associates P.C. Please read it carefully and discuss any questions you have with your physician. By signing this form, you are representing that you have read these documents, understand the information found in them, and you agree to comply with them, as applicable. 

Confidentiality: Your physician and LCA take your privacy and confidentiality very seriously. LCA complies with Federal and state laws regarding confidentiality of client information. Our Notice of Privacy Practices details how we use any information we collect, including for treatment, coordination of care, payment and other business operations. We will minimize the amount of information we share without your express consent, however there are certain circumstances in which we may disclose details of your care:

• Your physician may share information about your assessment and treatment in an anonymized way with members of the clinical team at LCA in order to improve your experience and guarantee that we are providing you with the most effective care possible. You may let us know that you do not want your information shared in this way by speaking with your physician.
• If there is suspected elder, dependent adult, or child abuse or neglect.
• If, in your physician’s judgment, you are in danger of harming yourself or another person, or are unable to care for yourself.
• If you communicate to your physician a serious threat of physical violence against another person; in these circumstances, your physician is required by law to inform both potential victims and legal authorities.
• If your physician is ordered by a court to release information as part of a legal proceeding.
• As otherwise required by law and detailed in our Notice of Privacy Practices.

Confidentiality of Alcohol and Drug Abuse Records:

As described in LCA’s Notice of Privacy Practices, patient medical records are protected by federal and state laws and regulations. Certain substance use disorder records are also protected by the federal regulations governing the Confidentiality of Substance Use Disorder Patient Records (42 CFR Part 2 (“Part 2”)). LCA works with certain Part 2 behavioral health providers who may provide therapeutic services involving substance use disorder (“Part 2 Program”). Records from any Part 2 Program that may be created in the course of your care through LCA are protected as described in this Notice. The following is a summary of the Part 2 regulations:

• Generally, a Part 2 Program may only acknowledge that an individual is present or disclose outside the Part 2 Program information identifying a patient as having or having had a substance use disorder in the following instances:
  • The patient’s written consent is obtained,
  • An authorizing court order is entered,
  • The patient’s records are disclosed to medical personnel to the extent necessary to meet a bona fide medical emergency,
  • The disclosure is for the purpose of conducting scientific research, or
  • The disclosure is for the purpose of an audit or evaluation.

Violation of the federal law and regulations at Part 2 is a crime and suspected violations may be reported as follows:

• Any violation of Part 2 may be reported:
  • To our Chief Privacy Officer at 270 East Lane, Burlingame, CA 94010; (800) 505-5972; or at [email protected]. 
  • The report of any violation of the regulations in this part may be directed to the United States Attorney for the judicial district in which the violation occurs.
  • To the Substance Abuse and Mental Health Services Administration (SAMHSA) office responsible for opioid treatment program oversight at: SAMHSA Opioid Treatment Program Compliance Officer contact the SAMHSA Center for Substance Abuse Treatment (CSAT) at 866-BUP-CSAT (866-287-2728) or [email protected] .
• If a patient commits a crime against personnel of the Part 2 Program, information related to the commission of that crime is not protected.
• Reports of suspected child abuse and neglect made under state law to appropriate state or local authorities are not protected.
• After receiving and reviewing this form, we will ask you to acknowledge that you have received it. If you have questions, or need to reach us for any other reason, you may contact the Chief Privacy Officer at 270 East Lane, Burlingame, CA 94010; (800) 505-5972; or at [email protected].

The Process of Medication Consultations and Visits: The process and outcome of medication visits may vary depending on the particular problems addressed, the symptoms of the client, and various other factors. While we cannot predict exactly what your experience will be like, we are committed to providing you with the most professional and ethical treatment possible.

Participation in a medication consultation and possible follow up visits can result in a number of benefits to you, including changes in your presenting symptoms. Since these visits often involve discussing unpleasant aspects of your life, you may experience uncomfortable and intense feelings like sadness, guilt, anxiety, frustration and anger. In addition, your physician may prescribe certain medications during your visit, and will discuss this with you directly, including possible side effects. There are no guarantees about what you will experience. Your physician’s role is to help guide you through care by asking relevant questions, providing treatment plans and recommendations, and monitoring your treatment progress.

During your first session, you will discuss with your LCA physician the reasons you are seeking a consultation, goals you would like to achieve, and any background information related to your presenting concerns. You may or may not be recommended medications as a result of this consultation. If you are recommended medications in our platform and choose to follow up, you will be asked to complete assessments between sessions to monitor and guide care. Follow up visits will assess the medication, effects and side effects. The physician will go over an informed consent regarding medications. Please be aware that the Federal Ryan Haight Online Pharmacy Consumer Protection Act of 2008 prevents physicians from prescribing controlled substances through telemedicine without an in-person medical evaluation, and your LCA physician cannot prescribe medications falling into this category.

Clinical Leave Evaluations. If applicable, participation in a clinical leave evaluation and possible follow up visits can result in a number of benefits to you, including changes in your presenting symptoms. Since these visits often involve discussing unpleasant aspects of your life, you may experience uncomfortable and intense feelings like sadness, guilt, anxiety, frustration and anger. There are no guarantees about what you will experience. Your provider’s role is to help guide you through care by asking relevant questions, providing treatment plans and recommendations, and monitoring your treatment progress. You acknowledge that an evaluation does not guarantee completion of paperwork or fulfillment of a leave.

Your Physician’s Credentials. Your physician’s credentials were made available to you before scheduling an appointment. If you have any questions about these credentials, please direct them to your physician. For those states that require it, you can find an explanation of the levels of regulation applicable to mental health clinicians under the STATE REGULATIONS section of this document. Please let your physician know if you will be traveling to another state or if you move to another state. In some cases, physicians are not able to provide services to you while you are located in another state, even temporarily.

The Lyra Platform: As part of care you will use Lyra Platform. You will need to access the Lyra Platform to participate in the video sessions, submit assessments and practices in between sessions, as well as to connect with your physician via secure messaging.

Your physician will orient you to using the Lyra Platform for the above purposes during your first session. If you decide to have your sessions with your physician by phone (without using the video option in the Lyra Platform), your physician will call you at the number you provided at registration. You will still need to use the Lyra Platform to complete and submit assessments.

Care Assessments: Before your first session, your physician will ask you to answer a set of questions that will help them get to know you and better tailor treatment to respond to your situation. Throughout your care, your physician will also assign other assessments to be completed before your sessions to inform treatment.

Therapeutic Focus: LCA providers do not make recommendations, write letters of recommendation or complete application forms related to medical leave, medical disability, fitness to work, child custody, or emotional support animals.

Video Care:

Please note that:

• As part of this program you will engage in telehealth sessions with your LCA physician.
• You understand that LCA and its physicians offer telehealth-based medical services, but that these services do not replace the relationship between you and your primary care physician. 
• All telehealth sessions are held by video using the Lyra Website.
• Your physician will initiate the video session with you at the scheduled time using the Lyra Website.
• The video conferencing technology will not be the same as an in-person session with a physician due to the fact that you will not be in the same room as your physician.
• In order to have the best results for this session, you should be in a quiet place with limited interruptions when you start the session.
• There are potential risks to this technology, including interruptions, unauthorized access and technical difficulties that are beyond the control of LCA. You agree to hold CA harmless for delays in evaluation or for information lost due to such technical difficulties or failures.
• Generally speaking, telehealth 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 telehealth, which include, but may not be limited to: the therapist may determine that the transmitted information is of inadequate quality, thus necessitating a face-to-face meeting with you; 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 adverse drug interactions or allergic reactions or other judgment errors in rare cases; and, it may become clear that telehealth is not an appropriate treatment format given your presenting symptoms or level of functioning, resulting in a recommendation that you obtain additional in-person care.
• Your Lyra physician or yourself can discontinue the telehealth session if it is felt that the videoconferencing connections are not adequate for the situation.
• Your LCA physician will inform you and obtain your consent if another person is present during the consultation, for any reason.
• Your LCA therapist will inform you and obtain your consent if another person is present during the consultation, for any reason. For example, persons may be present during the consultation other than the LCA therapist in order to operate the telehealth technologies. You will be informed of their presence in the consultation and will have the right to request the following: (a) omit specific details of your medical history/examination that are personally sensitive to you; (b) ask non-medical personnel to leave the telehealth examination; and/or (c) terminate the consultation at any time.
• There are alternatives to a telehealth session available, and a member of our Care Navigator Team can assist you in accessing those options.
• You can direct questions about your telehealth sessions at any time to your LCA physician or Lyra Care Navigator Team member.
• This consent will last for the duration of the relationship with your LCA physician, and it covers all telehealth sessions you may have.
• You can withdraw your consent for telehealth sessions  in the course of your care at any time for any reason or no reason, without affecting your right to future care or treatment, and Lyra will work with you to try to find a suitable alternative.
• The same confidentiality protections, limits to confidentiality, and rules around your records apply to a telehealth session as they would to an in-person session.
• Your LCA physician may decide to terminate telehealth services, if they deem it inappropriate for you to continue care through video sessions. Your LCA physician will work with other team members to identify another option for care. You understand that while you may expect anticipated benefits from the use of telehealth in your care, no results can be guaranteed or assured.
• By signing this consent you agree to work with your LCA physician to come up with a safety plan, including identifying one or two emergency contacts, in the event of a crisis situation during your sessions.

Video Recording: Your physician will record all video sessions using the Lyra Website for ongoing quality improvement, quality assurance, training, and development of our services. The video recordings are kept for 2 weeks and then deleted. If you do not agree to have your sessions recorded for quality purposes please let your physician know at your first appointment. We may retain some information from the session in a fully de-identified and anonymized format for longer than 2 weeks for ongoing quality assurance, training, and development of our services.

Your Location During Video Sessions: Like all health care providers, LCA’s physicians are licensed to offer services on a state by state basis. In order to ensure your LCA physician is appropriately licensed, we ask that you please search for a provider based upon your planned location at the time your session takes place. If your location changes at any point from one state to another, please let your LCA physician know as soon as possible. Please be aware that your LCA physician may not be able to provide services when you travel to a different state and is not able to provide services when you travel outside of the U.S.

Missed Appointments and Cancellations: Your physician requires at least 24 hours advance notice for cancellation of an appointment. If you are unable to attend your scheduled appointment due to circumstances beyond your control, please message your physician in the Lyra Website as soon as possible so we can reschedule your appointment to a more suitable time. Once an appointment is scheduled, you will be expected to attend unless you contact your physician to reschedule. You can also use email to reschedule; however, please note that receiving emails in your personal account may be unsecure. Failure to provide sufficient notice for cancellations and/or repeated no-shows for your appointment may impact your ability to schedule additional appointments with your physician. If you cancel or reschedule within 24 hours of a scheduled session, or you do not attend a scheduled session, you may be charged a $350.00 Late Cancellation Payment for your Initial Visit and a $200.00 Late Cancellation Payment for a Follow-Up visit.

In-Between Session Communication: If you need to contact your LCA physician between sessions, for non-urgent issues, please message them within the Lyra Website and they will address them as soon as possible. Your physician checks his/her messages in the Lyra Website regularly during business hours and will make every effort to return your message within 2 business days. These messages will remain available for thirteen (13) months and then will be deleted.

Scopes of Service

LCA physicians can only treat mental health related diagnoses. If you have a general medical concern, please address it with your primary care physician.

Your LCA physicians may recommend medications as part of your consultation or visits. All of the medications prescribed are FDA approved for at least one indication and in most cases will be FDA approved for what is being addressed in your visits. On occasion, physicians may prescribe medications for uses that are not included in the FDA approval. Many medications have studies or uses that become apparent after their initial approval. Recommendations in these cases are offered with careful clinical consideration and use of evidence-based literature/research.

Release of Information

As part of continuity of care or if your LCA physician has a medical concern, you authorize them to contact your primary care physician. You also authorize your LCA physician to access your pharmacy and lab history. You may also be asked to sign a release of information for others who may be helpful in your care.

Emergency Procedures: In a crisis, please call 911, go to the local emergency room. Please do not use the Lyra Care messaging or email if you are experiencing an emergency.

If you experience an emergency during your sessions with your LCA physician, or if your LCA physician becomes concerned about your personal safety, the possibility of you injuring someone else, or about you receiving proper psychiatric care, your LCA physician and LCA will work within the limits of the law to prevent you from injuring yourself or others and to ensure that you receive the proper medical care. For this purpose, LCA or your LCA physician may contact the person whose name you have provided on the biographical sheet as your emergency contact.

Social Media Policy: LCA and our physicians believe that adding clients as friends or contacts on social media sites (e.g., Facebook, LinkedIn, etc.) can compromise clients’ confidentiality and privacy. Consequently, given the importance of client confidentiality, your LCA physician will not accept friend or contact requests from current or former clients on any social networking site. If you have questions about this, please bring them up during your session.

Billing and Payments: The fees for your sessions may be partially or fully paid for by your, or your eligible sponsor’s, employer or Health Plan, with or without any cost share to you, as long as you are eligible, and as long as further sessions are considered clinically appropriate. Lyra’s services are not covered by Medicare. If you have insurance coverage through Medicare, you are financially responsible for any costs that are not covered by your employer or another Health Plan in which you are enrolled. Please check with Lyra at 1-(877)505-7147 prior to your session if you have any questions about how your session will be covered. Please note that certain professional services outside of the presenting problems, such as chart preparation requests and participation in legal proceedings, may be outside the services paid for by your employer or Health Plan and may incur additional fees. Any additional fees will be discussed and agreed upon when they are requested. Fees for services may be subject to change in the future and may also change if you move to another state. If you have questions about the full cost of a session prior to any health plan cost coverage, you may contact the Lyra Care Navigator Team at [email protected]

Research, Writing, Teaching: Your physician and others at LCA conduct internal research to improve our services, training, and supervision. Your physician may use information about you and your treatment in any of these ways. Your physician or others at LCA may also prepare publications for professional and/or lay audiences, and any use of information about your treatment would be only in an anonymized and/or de-identified way for these publications.

Length of Treatment: Your course of treatment will be individualized depending on the intensity and duration of your presenting concerns, your level of engagement and active participation in the treatment plan, and the specific nature of your concerns.

Ending Treatment: You may withdraw from treatment at any time. Your physician recommends that you discuss your plan to end treatment with them before taking action, so that they have an opportunity to offer further recommendations or referral options. Additionally, we recommend not discontinuing medications abruptly and without discussing with your physician

If at any point during care your physician assesses that the sessions are not effective in helping you reach the therapeutic goals, he/she will discuss this with you and, if appropriate, end treatment. In such a case, they will work with you and the Lyra Care Navigator Team to identify alternative options.

If you do not keep your scheduled appointments and do not respond to communications from your physician, we will assume you have elected to end your treatment and we will close your case. If this occurs, and you wish to resume your treatment, please contact the Lyra Care Navigator Team to reinitiate care.

State Regulations: Please read the disclosures set forth next to the state in which you are located at the time of the telehealth encounter, as set forth below.

TREATMENT AGREEMENT

If at any time you have questions about the details above, please ask your physician or the Lyra Care Navigator Team. By continuing your sessions with your physician you accept and agree to abide by the contents and terms of this agreement and consent to participate in evaluation and/or treatment.

Notice of Open Payments Database

For informational purposes only, a link to the federal Centers for Medicare and Medicaid Services (CMS) Open Payments web page is provided here. The federal Physician Payments Sunshine Act requires that detailed information about payment and other payments of value worth over ten dollars ($10) from manufacturers of drugs, medical devices, and biologics to physicians and teaching hospitals be made available to the public.