Consent for Mental Health Evaluation 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) evaluator, and Lyra Clinical Associates P.C. Please read it carefully and discuss any questions you have with your evaluator. 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 evaluator 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 evaluator 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.
• If there is suspected elder, dependent adult, or child abuse or neglect.
• If, in your evaluator’s judgment, you are in danger of harming yourself or another person, or are unable to care for yourself.
• If you communicate to your evaluator a serious threat of physical violence against another person; in these circumstances, your evaluator is required by law to inform both potential victims and legal authorities.
• If your evaluator 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 Mental Health Evaluations and Visits: The process and outcome of mental health evaluation 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 mental health 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 evaluator’s role is to conduct an independent evaluation for leave of absence, medical accommodations, treatment recommendations, and to support connecting you with the appropriate care for your presenting concern when clinically indicated  by asking relevant questions, providing treatment plans and recommendations, and monitoring your treatment progress.

During your first session, you will discuss with your LCA evaluator 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 a leave of absence, medical accommodations, adjustment to your current treatment plan, or additional interventions as a result of this consultation. If you are offered recommendations and choose to follow up, you will be asked to complete assessments between sessions to monitor and guide care recommendations. Follow up visits will assess your adherence and response to treatment recommendations. By signing this form, you acknowledge that an evaluation does not guarantee completion of paperwork or fulfillment of a leave request.  

Your Evaluator’s Credentials. Your evaluator’s credentials were made available to you before scheduling an appointment. If you have any questions about these credentials, please direct them to your evaluator. 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 evaluator know if you will be traveling to another state or if you move to another state. In some cases, evaluators are not able to provide services to you while you are located in another state, even temporarily.

Lyra Platform: As part of care you will use the 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 evaluator via secure messaging.

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

Video Care: Please note that:

• As part of this program you will engage in telehealth sessions with your LCA evaluator.
• All telehealth sessions are held by video using the Lyra Website.
• Your evaluator 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 an evaluator due to the fact that you will not be in the same room as your evaluator.
• 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 LCA 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 evaluator 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;
• Your Lyra evaluator or yourself can discontinue the telehealth session if it is felt that the videoconferencing connections are not adequate for the situation.
• Your LCA evaluator 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 evaluator 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.
• You can direct questions about your telehealth sessions at any time to your LCA evaluator or Lyra Care Navigator Team member.
• This consent will last for the duration of the relationship with your LCA evaluator, 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 evaluator may decide to terminate telehealth services, if they deem it inappropriate for you to continue care through video sessions. Your LCA evaluator 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 evaluator 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 evaluator will ask you at the start of each session if you consent to the session being recorded. If you consent, your evaluator will record the session to enable preparation of a draft summary note of the session, using our artificial intelligence tools, and for the purposes of quality assurance, training, and the development and improvement of our services and artificial intelligence tools. The draft note will be reviewed by your evaluator prior to inclusion in the clinical record.

Video recordings are kept securely for 2 weeks and then deleted. No one other than the evaluator (including you) has permission to record sessions.

Content of the session may be retained indefinitely in a de-identified and/or aggregated format, and used for quality assurance, training, and the development and improvement of our services and artificial intelligence tools.

Your participation in video recording is voluntary. You have the right to refuse to be recorded and to withdraw your consent at any time. Choosing not to be recorded will not affect the availability or quality of the care you receive.

Your Location During Video Sessions: Like all health care providers, LCA’s evaluators are licensed to offer services on a state by state basis. In order to ensure your LCA evaluator 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 evaluator know as soon as possible. Please be aware that your LCA evaluator 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 evaluator 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 evaluator 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 evaluator 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 evaluator. 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 Late Cancellation Payment for your Initial Visit and a Late Cancellation Payment for a Follow-Up visit.

In-Between Session Communication: If you need to contact your LCA evaluator between sessions, for non-urgent issues, please message them within the Lyra Website and they will address them as soon as possible. Your evaluator checks their 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.

Scope of Service: LCA evaluators provide an assessment of mental health symptoms and a recommendation with regard to whether they meet the clinical threshold for a mental health disability. LCA evaluators do not approve nor deny short-term disability claims. 

Emergency Procedures: In a crisis, please call 911 or go to the local emergency room. Please do not use the Lyra Care messaging or email if you are experiencing an emergency. If you would like to speak to someone for support prior to your appointment, or if you experience distress prior to your appointment, please use the Lyra Care Navigator Team number (877-505-7147) for non-emergency situations. Your Lyra evaluator may not be available to respond to you immediately due to variations in working hours. Your Lyra evaluator will respond to messages within 48 business hours of receipt.

If you experience an emergency during your sessions with your LCA evaluator, or if your LCA evaluator becomes concerned about your personal safety, the possibility of you injuring someone else, or about you receiving proper psychiatric care, your LCA evaluator 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 evaluator may contact the person whose name you have provided on the biographical sheet as your emergency contact.

Social Media Policy: LCA and our evaluators 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 evaluator 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 note that certain professional services outside of the presenting problems, 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 evaluator and others at LCA conduct internal research to improve our services, training, and supervision. Your evaluator may use information about you and your treatment in any of these ways. Your evaluator 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 Engagement: Your course of engagement 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 Engagement: You may withdraw from engagement with your evaluator at any time. Your evaluator recommends that you discuss your plan to end care with them before taking action, so that they have an opportunity to offer further recommendations or referral options. 

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

TREATMENT AGREEMENT

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

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.

State	What You Should Know	Relevant Board Contact Information
Alaska	You understand that your primary care provider may obtain a copy of your records of your telehealth encounter. This document is intended to provide you with all of the information is required by the Board of Professional Counselors which regulates all licensed professional counselors.  You may contact the Board with any questions or concerns.	Board of Professional Counselors Division of Corporations, Business & Professional Licensing P.O. Box 110806 Juneau, AK 99811-0806 Phone: (907) 465-2551 Email: [email protected]
Arizona	You are entitled to all existing confidentiality protections, including where a provider may only disclose all or part of your medical record and payment record as authorized by state or federal law or written authorization signed by you or your health care decision maker, pursuant to A.R.S. § 12-2292.  You also understand all medical reports resulting from the telemedicine consultation are part of your medical record as defined in A.R.S. § 12-2291.  You also understand dissemination of any images or information identifiable to you for research or educational purposes shall not occur without your consent, unless authorized by state or federal law.  Ariz. Rev. Stat. Ann. § 36-3602(D).	Board of Behavioral Health Examiners 1740 West Adams Street, #3600 Phoenix, AZ 85007 Main Number: 602-542-1882 Fax Number: 602-364-0890 [email protected]
Colorado	If you have a concern or complaint about the mental health professionals providing care to you, you may contact a board agency to assist you. You are entitled to the consent requirements outlined under 2 CO ADC 502-1:21.170.4.  The confidentiality of your individual records, including all medical, mental health, substance use, psychological, and demographic information shall be protected with the applicable state and federal laws and regulations, as provided under 2 CO ADC 502-1:21.170.2.	State Board of Licensed Professional Counselor Examiners, State Board of Social Work Examiners, State Board of Marriage and Family Therapist Examiners, State Board of Addiction Counselor Examiners, and State Board of Psychologist Examiners 1560 Broadway, Suite 1350, Denver, Colorado 80202, (303) 894-7800 Email: [email protected]
Connecticut	You understand that each telehealth provider shall, at the time of the initial telehealth interaction, ask you whether you consent to that provider’s disclosure of records concerting the telehealth interaction to your primary care provider.  You further understand that your primary care provider may obtain a copy of your records of your telehealth encounter, upon your consent. Conn. Gen. Stat. Ann. § 19a-906(d).	Connecticut Department of Public Health Professional Counselor Licensure 410 Capitol Ave., MS #12 APP P.O. Box 340308 Hartford, CT 06134 Phone: (860) 509-7603 Fax: (860) 707-1980 Email:  [email protected]
District of Columbia	You have been informed of alternate forms of communication between you and a physician for urgent matters.  D.C. Mun. Regs. tit. 17, § 4618.10.  Relevant communications with the physician, including those done via electronic methods shall be documented and filed in your medical record. D.C. Mun. Regs. tit. 17, § 4618.9.	Professional Counseling Licensing 899 North Capitol Street, NE, Washington, DC 20002 Phone: (202) 442-5955 Fax: (202) 442-4795 Department of Health Board of Medicine 899 North Capitol Street, NE Washington DC, 20002 Email: [email protected]
Georgia	You have been given clear, appropriate, accurate instructions on follow-up in the event of needed emergent care related to the treatment. Ga. Comp. R. & Regs. 360-3-.07(a)(7).	Georgia Composite Medical Board 2 Peachtree Street, NW 6th Floor Atlanta, GA 30303-3465 Email: [email protected]
Idaho	If you need to register a formal complaint about a physician, you may visit the medical board’s website, here.  You further understand that your informed consent for the use of telehealth services shall be obtained by applicable law. Idaho Statutes 54-5708.	Board of Medicine: Logger Creek Plaza 345 Bobwhite Ct., Suite 150 Boise, ID 83706 [email protected] Division of Professional Licenses: 11351 W. Chinden Blvd., Bldg. #6 Boise, ID 83714
Illinois	If you need to register a formal complaint about a professional regulated under the Illinois Division of Professional Regulation, you may file a formal complaint here: https://www.idfpr.com/admin/DPR/DPRcomplaint.asp	Chicago: 555 West Monroe St., 5th Floor Chicago, IL 60661 Springfield: 320 W. Washington Street, 3rd Floor, Springfield IL Phone: 1 (888) 473-4858
Indiana	If you have a concern or complaint about the non-physician mental health professionals providing care to you, you may contact a board agency to assist you. You may file a complaint here: https://www.in.gov/pla/file-a-complaint/ If you want to register a formal complaint about a physician, you should visit the medical board’s website, here: https://www.in.gov/attorneygeneral/2434.htm	Indiana Professional Licensing Agency 402 W. Washington St., Room W072 Indianapolis, Indiana 46204 Staff Phone Number: (317) 234-2054 Staff E-mail: [email protected] Agency Fax: (317) 233-4236
Iowa	If you have a concern or complaint about the non-physician mental health professionals providing care to you, you may contact a board agency to assist you. You may find information related to filing a complaint here: https://idph.iowa.gov/Licensure/Iowa-Board-of-Behavioral-Science If you want to register a formal complaint about a physician, you should visit the medical board’s website, here: https://medicalboard.iowa.gov/consumers/filing-complaint. To file a complaint, fill in the form below or fill out the complaint form  and email it to the medical board at [email protected].	Iowa Board of Medicine 400 SW 8th St., Suite C Des Moines, IA 50309 515-281-5171 Email: [email protected].
Kansas	You understand that if you have a primary care or other behavioral health treating provider and if you consent to us sharing your information with such provider, then we are obligated to send within three business days a report to such primary care or other treating physician of the treatment and services rendered by [PC] during the telemedicine encounter.  Kan. Stat. Ann. § 40-2,212(2)(d)(2)(A). The process for filing a complaint may be found here: http://www.ksbha.org/complaints.shtml	Kansas Board of the Healing Arts 800 SW Jackson, Lower Level – Suite A, Topeka, KS 66612 (785) 296-7413; Fax (785) 368-7102
Kentucky	You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here: https://kbml.ky.gov/board/Pages/default.aspx. Information related to filing grievances may be found here: https://kbml.ky.gov/grievances/Documents/Information%20on%20Filing%20A%20Grievance.pdf	Kentucky Board of Medical Licensure 310 Whittington Parkway Suite 1B Louisville, KY 40222
Louisiana	You understand the role of other health care providers that may be present during the consultation, other than the [PC] provider. 46 La. Admin. Code Pt XLV, § 7511.	Licensed Professional Counselors Board of Examiners 11410 Lake Sherwood Ave North Suite A Baton Rouge, LA 70816 225-295-8444 (phone) 225-295-8448 (fax) [email protected]
Maine	If you have a concern or complaint about the mental health professionals providing care to you, you may contact a board agency to assist you. If you want to register a formal complaint about a physician, you should visit the medical board’s website, here: https://www.maine.gov/md/discipline/file-complaint.html	Complaint Coordinator Office of Licensing and Registration 35 State House Station Augusta, ME 04333 Tel: (207) 624-8660 www.maine.gov/professionallicensing
Maryland	The knowledge, experiences, and qualifications of the consultant providing data and information to the provider of the telehealth services need not be completely known to and understood by the provider. The quality of transmitted data may affect the quality of services provided by the provider. Changes in the environment and test conditions could be impossible to make during delivery of telehealth services. Telehealth services may not be provided by correspondence only. Md. Code Regs. 10.41.06.04. If you want to register a formal complaint about a physician, you should visit the medical board’s website, here: https://www.mbp.state.md.us/resource_information/faqs/resource_faqs_complaints.aspx	Maryland Board of Physicians 4201 Patterson Avenue Baltimore, MD 21215 Tel: (410) 764-4777
Nebraska	If you are a Medicaid recipient, you retain the option to refuse the telehealth consultation at any time without affecting your right to future care or treatment and without risking the loss or withdrawal of any program benefits to which the patient would otherwise be entitled. All existing confidentiality protections shall apply to the telehealth consultation. You shall have access to all medical information resulting from the telehealth consultation as provided by law for access to your medical records. Dissemination of any patient identifiable images or information from the telehealth consultation to researchers or other entities shall not occur without your written consent. You understand that you have the right to request an in-person consult immediately after the telehealth consult and you will be informed if such consult is not available. Neb. Rev. Stat. Ann. § 71-8505; 471 Neb. Admin. Code § 1-006.05.	Nebraska DHHS Licensure Unit Attn: [insert relevant profession] PO Box 94986 Lincoln NE 68509-4986 Complaints: https://dhhs.ne.gov/Pages/Complaints.aspx
New Hampshire	You understand that the provider may forward your medical records to your primary care or treating provider.  N.H. Rev. Stat. § 329:1-d.	Office of Professional Licensure & Certification 7 Eagle Square Concord NH, 03301 Phone: 603-271-2152
New Jersey	You understand that you have the right to request a copy of your medical information and you understand your medical information may be forwarded directly to your primary care provider or health care provider of record, or upon your request, to other health care providers. N.J. Rev. Stat. Ann. § 45:1-62.	New Jersey Board of Medical Examiners [email protected] (609) 826-7100 Professional Counselors Examiners [email protected] (973) 504-6582
Ohio	You understand that the provider may forward your medical records to your primary care or treating provider. Ohio Admin. Code 4731-11-09(C).	Ohio Medical Board Complaints may be sent to: [email protected] or call the Medical Board at 614-466-3934 and choose option 1 to speak to the complaint department. You may also leave a message on the State Medical Board of Ohio’s Confidential Complaint Hotline at 1-833-333-SMBO (7626).
Oklahoma	The licensing website is www.ok.gov/behavioralhealth where you can access the laws and regulations that govern the practitioner’s license. The practitioner will furnish you with printed materials about the requirements of his/her licensure if you so desire. You may also register a formal complaint about a physician by visiting: http://www.okmedicalboard.org/complaint	You may contact (without giving your name), the State Board of Behavioral Health Licensure at: State Board of Behavioral Health Licensure 3815 North Santa Fe, Suite 110, Oklahoma City, OK 73118 Telephone: (405) 522-3696 See column to left for physicians.
Oregon	If you have a concern or complaint about the mental health professionals providing care to you, you may contact a board agency to assist you. You understand that the provider may ask if you need more detail. ORS 17-52-677.07	The Board of Licensed Professional Counselors and Therapists 3218 Pringle Rd SE, #120, Salem, OR 97302-6312 Telephone: (503) 378-5499 Email: [email protected] Website: www.oregon.gov/OBLPCT
Pennsylvania	If you have a concern or complaint about the mental health professionals providing care to you, you may contact a board agency to assist you. You also understand that you may be asked to confirm your consent to behavioral health or telepsychiatry services. 40 PS §1303.504(b).	State Board of Social Workers, Marriage and Family Therapists and Professional Counselors P.O. Box 2649, Harrisburg, PA 17105-2649 717-783-1389
South Carolina	The information you share in psychotherapy is protected health information and is generally considered confidential by both South Carolina state law and federal regulations, with some limited exceptions (e.g., may be shared with another healthcare provider, required by subpoena).  Your mental health practitioner is also mandated by standards – through Duties to Warn – to breach confidentiality if: (1) you are threatening self-harm or suicide; (2) you are threatening to harm another or homicide; (3) a child has been or is being abused or neglected; and/or (4) a vulnerable adult has been or is being abused or neglected. You also understand that if you are a Medicaid beneficiary, you can withdraw your consent at any time.	South Carolina Board of Examiners for The Licensure of Professional Counselors, Marriage and Family Therapists, and Psycho-educational Specialists P.O. Box 11329, Columbia, South Carolina 29211-1329 Telephone: 803-896-4652
Tennessee	You understand that you may request an in-person assessment before receiving a telehealth assessment if you are a telehealth recipient. The information you share in psychotherapy is protected health information and is generally considered confidential by both Tennessee state law and federal regulations, with some limited exceptions (e.g., may be shared with another healthcare provider, required by subpoena).  Your mental health provider may also disclose information without consent: (1) if disclosure is necessary for other duties that the mental health provider is bound by, (2) if it is necessary to assure service or care is the least drastic means, (3) due to a court order, (4) if it is solely information to a residential service recipient, (5) to facilitate continuity of service to another health care provider, (6) if a custodial agent for another state agency that has legal custody of the service cannot perform the agent’s duties, or (7) it is necessary for the preparation of a post-mortem examination. Tenn. Code Ann. §33-3-105.	Tennessee Department of Health 710 James Robertson Parkway Nashville, TN 37243 [email protected]
Texas	You understand that your medical records may be sent to your primary care physician. Tex. Occ. Code Ann. § 111.005. You have been informed of the following notice: NOTICE CONCERNING COMPLAINTS -Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board may be reported for investigation at the following address: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Assistance in filing a complaint is available by calling the following telephone number: 1-800-201-9353, For more information, please visit our website at www.tmb.state.tx.us.  AVISO SOBRE LAS QUEJAS- Las quejas sobre médicos, asi como sobre otros profesionales acreditados e inscritos del Consejo Médico de Tejas, incluyendo asistentes de médicos, practicantes de acupuntura y asistentes de cirugia, se pueden presentar en la siguiente dirección para ser investigadas: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Si necesita ayuda para presentar una queja, llame al: 1-800-201-9353, Para obtener más información, visite nuestro sitio web en www.tmb.state.tx.us	See column to left.
Utah	You understand (i) the fees that may be charged to you for the telehealth service; (ii) to whom your health information may be disclosed and for what purpose, and have received information on any consent governing release of your patient-identifiable information to a third-party; (iii) your rights with respect to patient health information; (iv) appropriate uses and limitations of the site, including emergency health situations. You were warned of: potential risks to privacy notwithstanding the security measures and that information may be lost due to technical failures, and agree to hold the provider harmless for such loss. You have been provided with the location of [PC’s] website and contact information. You understand that you are able to select a provider of your choice, to the extent possible. You are able to select a pharmacy of choice. You are able to a (i) access, supplement, and amend your patient-provided personal health information; (ii) contact your provider for subsequent care; (iii) obtain upon request an electronic or hard copy of your medical record documenting the telemedicine services, including the informed consent provided; and (iv) request a transfer to another provider of your medical record documenting the telemedicine services. Utah Admin. Code r. 156-1-602.	Utah Medical Board (801) 530-6628 (866) 275-3675 [email protected]
Vermont	Upon the Office of Professional Regulation’s receipt of a complaint, an administrative review determines if the issues raised are covered by the applicable professional conduct statute. If so, a committee is assigned to investigate, collect information, and recommend action or closure to the appropriate governing body. All complaint investigations are confidential. Should the investigation conclude with a decision for disciplinary action against a professional’s license and ability to practice, the name of the license holder will then be made public. If you want to register a formal complaint about a physician, you should visit the medical board’s website, here: http://www.healthvermont.gov/health-professionals-systems/board-medical-practice/file-complaint  Board of Osteopathic Examiners can be found at: https://www.sec.state.vt.us/professional-regulation/file-a-complaint-employer-mandatory-reporting.aspx	Consumers who have inquiries or wish to obtain a form to register a complaint regarding a professional counselor may do so by calling the Office of Professional Regulation at (802) 828-1505, or by writing to the Director of the Office, Secretary of State’s Office, 89 Main Street, 3rd Floor, Montpelier, VT 05620-3402. For physicians, see column to left.
Washington	You understand the purposes of and resources available to you surrounding this treatment, including the right to refuse treatment, and your responsibility in choosing a provider and treatment that best suits your needs. RCW 18.19.060. The information you share in psychotherapy is protected health information and is generally considered confidential by both Washington state law and federal regulations, with some limited exceptions (e.g., may be shared with another healthcare provider, required by subpoena).  RCW 18.19.180. Counselors practicing counseling for a fee must be credentialed with the department of health for the protection of the public health and safety. Credentialing of an individual with the department of health does not include a recognition of any practice standards, nor necessarily imply the effectiveness of any treatment. The purpose of the Counselor Credentialing Act, chapter 18.19 RCW, is to: (A) Provide protection for public health and safety; and (B) Empower the citizens of the state of Washington by providing a complaint process against those counselors who would commit acts of unprofessional conduct.  Clients have the right to choose counselors who best suit their needs and purposes. A copy of the acts of unprofessional conduct in RCW 18.130.180 can be found on the Washington State Legislature’s website at this address http://apps.leg.wa.gov/RCW/default.aspx?cite=18.130.180.	Here is the name, address, and contact telephone number within the department of health for complaints. Washington State Department of Health Health Professions Quality Assurance P.O. Box 47865 Olympia, WA 98504-7865 (360) 236-4700
Wyoming	Wyoming has implemented a privileged communication statute that states that, when involved in legal proceedings (civil, criminal or juvenile) clients retain the right to privacy, unless these specific circumstances exist: (a) abuse or harmful neglect of children, the elderly or disabled or incompetent individuals is known or reasonably suspected; (b) the validity of a will of a former client is contested; (c) information related to counseling is necessary to defend against a malpractice action brought by a client; (d) an immediate threat of physical violence against a readily identifiable victim is disclosed to the counselor; (e) in the context of civil commitment proceedings, where an immediate threat of self-inflicted harm is disclosed to the counselor; (f) the client alleges mental or emotional damages in civil litigation or his/her mental or emotional state becomes an issue in any court proceeding concerning child custody or visitation; (g) patient or client is examined pursuant to a court order; or (h) in the context of investigations and hearings brought by the client and conducted by the board, where violations of this act are at issue.  Providers will adhere to the Code of Ethics of the National Association of Social Workers; American Counseling Association; American Association of Marriage and Family Therapy; or National Association of Alcoholism and Drug Abuse Counselors, whichever is applicable for the provider’s profession.	Wyoming Mental Health Profession Licensing Board 2001 Capitol Ave, Room 105 Cheyenne, WY 82002 Tel: (307) 777-3628 Fax: (307) 777-3508 [email protected]