DO NOT USE THIS SERVICE IF YOU MAY BE EXPERIENCING A MEDICAL EMERGENCY. Our services are not to be used for urgent or emergency consultations nor are they a replacement for primary care services. If you are in crisis or have thoughts of harming yourself or others, (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).

Purpose

The purpose of this Informed Consent and Patient Agreement (the “Informed Consent”) is to explain the benefits and risks of therapy and medication management services provided in-person or via telehealth technologies, and provide information what you can expect in connection with your treatment by Headlight Health Medical Group PLLC, Sokyahealth Medical Group, P.C. (CA), Sokyahealth Medical Group, P.C. (OR), Sokyahealth, LLC, Shashita Inamdar M.D., and Achieve Medical Alaska, LLC (collectively, “Headlight Health”).

If you consent, your Headlight Health provider (the “Provider”) will provide therapy services and (if applicable) medication management services to you in-person or via telehealth technologies. Therapy is meant to provide a safe and confidential space for you to meet your needs. If the Provider recommends medication management, you may be prescribed one or more pharmaceutical drugs to treat the symptoms of emotional, behavioral, and/or mood disorders.

Important Information Regarding Your Treatment, Including Potential Risks and Benefits

Therapy and medication management (if applicable) have been shown to be effective in numerous studies. These services may help you feel better and relieve symptoms of emotional, behavioral, and mood disorders (e.g., anxiety and depression). Your assertiveness, communication, coping skills, mood, and relationships may improve. You may also benefit in unexpected ways. Medication management may help prevent or decrease risks associated with the use of medicines.

There are also potential risks associated with therapy and medication management (if applicable), which include, but may not be limited to:

1. Therapy Services: You may experience unpleasant feelings or bad memories in connection with your therapy sessions. It may feel uncomfortable for you to discuss some of your issues with the Provider. You may remember past problems or uncover new issues. There may be an increase in symptoms when you are attempting to make changes in your life. There is a risk that therapy will fail to help you meet your goals.

2. Medication Management (if applicable): Medications may have negative side effects. You are responsible for reviewing the risk and benefits that accompany your prescribed medications. These side effects may be increased if you take the wrong dose, miss one or more doses, and/or take the wrong medication. While medication management is aimed at decreasing risks associated with the uses of medications, it is not a guarantee and does not decrease all risks.

Important Information Regarding Treatment via Telehealth, Including Potential Risks and Benefits

Telehealth is the use of electronic information and communication technologies to enable the sharing of medical information and the delivery of healthcare between you and the Provider while you and the Provider are at different locations. The delivery of healthcare, including behavioral/mental healthcare, via telehealth allows you and the Provider to establish a relationship, much as you would during a traditional face-to-face appointment. Your telehealth encounter may include interaction through and with the use of some of the following technologies: telephone calls, synchronous video (e.g., videoconferencing) and/or asynchronous technology, such as store-and-forward technology to exchange medical data and secure messaging portal communication.

The benefits of telehealth include improved access to medical, behavioral, healthcare services, including the expertise of specialists and consultants who may not otherwise be available to you.

There are potential risks to using telehealth technology, including interruptions to the connection, images and other information transmitted not being clear enough to be useful for the consultation, unauthorized access, and technical difficulties. However, either the Provider or you can discontinue your telehealth visit if the telehealth technologies are not adequate for the situation or if the information obtained via telehealth was not sufficient or if telehealth is inappropriate for any reason. Other potential risks to using telehealth services include breach of privacy of protected health information due to security breaches or failures, as well as adverse drug interactions, allergic reactions, complications, or other errors due to your failure to provide complete medical information or records.

Headlight Health uses security protocols to protect the confidentiality of information shared via telehealth technologies.

Alternative methods of care, such as in-person services, may be available to you. You may choose an alternative at any time, if available.

Follow-Up Care; Emergencies: Headlight Health does not provide primary care services. If a technical failure prevents you from communicating with the Provider or if you believe telehealth will not provide sufficient safety and quality, you should contact Headlight Health or your Provider. In the event of an urgent health issue or concern, seek care in-person, at a facility or provider equipped to deliver urgent or emergent care. IF YOU ARE IN CRISIS OR HAVE THOUGHTS OF HARMING YOURSELF OR OTHERS, (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).

Important Information About Medication Management

All medication management services are provided at the professional discretion of the Provider. Prescriptions for some medications may only be written during scheduled in-person appointments and may only be requested at that time. You may be requested to make an appointment to see your Provider in person to receive refills of your medications. Requests for refills may take up to three business days to be processed by your Provider and each pharmacy’s processing time may vary. Contact your pharmacy for refill timing questions after your Provider sends the refill request to the pharmacy. Medication is not guaranteed as part of the services provided.

Scheduling and Cancellations

Scheduled appointment times are reserved specifically for you. Reminder calls or texts are a courtesy, and it is ultimately your responsibility to notate scheduled dates and times. Failure to provide notice 24 hours prior to a scheduled therapy session or a scheduled medication management appointment may result in a fee of $100, and your credit card on file will be charged. A credit card will be held on file to guarantee payment and may be charged without notification for missing appointments or providing notice outside of the requested timeframes. Multiple late cancellations or missed appointments may result in your discharge by Headlight Health.

Privacy

Headlight Health uses and discloses your “protected health information” as described in our HIPAA Notice of Privacy Practices.

Financial Responsibility and Assignment of Benefits

Your Financial Responsibility. Some or all of the services may be covered in full by your health plan. However, you understand that your health plan may not pay the full amount of the actual bill for services. Non-covered services are not reimbursable by your health plan and will be charged an out-of-pocket fee. Non-covered services may include consultations with other professionals, court appearances, preparation of disability forms, drafting letters such as excuses from work, school/work accommodations, and other document preparation such as completing legal forms, conservatorship petitions, letters, or similar documents. Any request for these services must be done directly with your Provider at the time of your scheduled appointment. If you are insured by a governmental health plan, we will bill such health plan for services provided to you. If you do not have insurance or choose not to have us bill your commercial insurance plan, you are responsible for all fees and must pay the full amount of the actual bill for services.

You acknowledge and agree that you are fully responsible for paying Headlight Health any amounts not paid by your health plan, including charges for non-covered services, and all copayments, coinsurance, and deductibles. Payment is expected on or before the payment due date set forth in the statement or bill. You further acknowledge and agree that it is your responsibility to inquire about the costs of services in advance when such costs are unclear to you. You agree to provide us with proof of insurance and identification upon request, including potentially before an appointment or interaction through which the Provider provides services. In the event any collection action is necessary to collect amounts you owe to Headlight Health, you agree to pay all expenses associated with such action, including but not limited to, collection agency fees and attorneys’ fees.

Assignment of Benefits. You hereby assign to Headlight Health all of your right, title, and interest in any and all health insurance or other health care benefits payable to you or on your behalf by any health plan, including private insurance, Medicare and any other health plan for medical or other professional services or supplies furnished by Headlight Health. If you claim benefits under Title XVIII of the Social Security Act (Medicare), you hereby certify that the information you provide in applying for payment of such benefits is correct and you specifically authorize Headlight Health (or third parties working on behalf of Headlight Health, including Headlight Health, Inc.) to release to the Centers for Medicare and Medicaid Services and its Medicare administrative contractors any information needed for this or any related Medicare claim. Without limiting the foregoing, you authorize Headlight Health (or third parties working on behalf of Headlight Health) to release to your health plan information necessary to process claims for payment for services or supplies provided to you, and you authorize direct payment to Headlight Health of all benefits payable to you for such services. In the event a health plan pays you directly, you agree to immediately pay such amounts to Headlight Health.

BY CLICKING “I AGREE” OR SIMILAR WHEN THE OPTION IS PRESENTED TO YOU, OR BY ENGAGING IN TREATMENT SERVICES WITH HEADLIGHT HEALTH, YOU UNDERSTAND AND AGREE TO THE FOLLOWING:

1. You understand the risk and benefits of therapy services and medication management services (if applicable).

2. You have read and understand the information in this Informed Consent and, if you have questions, you will ask Headlight Health or your Provider and ensure that all of your questions are answered to your satisfaction.

3. You acknowledge that you have read and you understand the disclosures set forth next to the state in which you are located at the time of the telehealth encounter, as set forth in the “State-Specific Disclosures” section below.

4. Therapy and medication management services are not designed for emergency situations.

5. You understand that a missed appointment fee of $100 may be charged to your credit card on file if you do not cancel your appointment more than 24 hours in advance. Multiple late cancellations or missed appointments may result in your discharge by Headlight Health.

6. You understand that all appointments must take place at home or in a safe location, and may not be conducted under other circumstances (e.g., when you are driving or otherwise may be unsafe while participating in the appointment).

7. Your visit will involve review of your medical data for screening, assessment, or management purposes, and that you are responsible for any follow-up with your primary care provider or another specialist regarding any results, concerns, or abnormalities that may be identified based on screening, assessment, or management by the Provider.

8. You acknowledge and agree that the information you provide to your Provider is truthful, accurate, and correct to the best of your knowledge. You understand that your Provider may rely on the information that you provide to make a diagnosis and determine the appropriate treatment(s) for you, including prescribing medication(s). You understand that providing inaccurate information to your Provider could (1) result in an incorrect diagnosis, (2) negatively impact your care, and (3) risk your safety.

9. Headlight Health and the Provider may communicate with you, including about your personal medical and mental health information by email, by phone call or leaving you a voicemail message, and by texting you at the mobile number you have provided. You understand that the above methods of unencrypted communication will be used to communicate with you about Provider’s services, for your convenience, and you accept all risks associated with them (including, without limitation, risks of improper exposure of your medical information to individuals with access to your phone and/or email account).

10. Although efforts are taken to safeguard your confidentiality, no guarantees of confidentiality can be made. If you participate in any group session, any group participant has the ability to save and share your confidential information, even though all participants have agreed to confidentiality.

11. You are financially responsible for any payments that apply to your visit that are not covered by your commercial or government health insurance plan. The Provider has a financial relationship with Headlight Health and that you are free to obtain services elsewhere.

12. You consent to Headlight and your Provider making video or audio recordings of your sessions. You consent to Headlight and your Provider using and disclosing such recordings for treatment, payment, and health care operations, and as otherwise permitted by law. You understand that Headlight Health and your Provider may use an artificial intelligence tool, sometimes called an “AI Scribe,” that listens to your sessions with your Provider and generates clinical notes or summaries for your Provider to review. You consent to Headlight Health and your Provider using AI Scribe technology during your sessions.

13. A summary of your visit may also be sent to your primary care provider of record in order to facilitate continuing care. You understand that you have the right to inspect and obtain copies of all information received and recorded during any visit, subject to the policies of the Providers involved in your care. You may be charged a fee for copies of records in accordance with applicable state laws.

14. If you need extra support in-between therapy sessions, let your Provider know.

15. You are responsible for notifying your Provider of any side effects of your medication and if you suspect or know that you are pregnant or if you plan to become pregnant in the near future. Notify your Provider any time another healthcare provider prescribes you a new medication or if there are significant changes in your psychiatric or medical condition.

16. To the extent required by law, you consent to Headlight Health and third parties who work on behalf of Headlight Health (including Headlight Health, Inc.) using and disclosing your health information, including your Highly Confidential Information, for purposes of treatment, payment, health care operations, and as otherwise described in the Headlight Health Notice of Privacy Practices. “Highly Confidential Information” means information about substance use disorder treatment, mental health diagnoses and treatment, HIV/AIDS testing or treatment or status, communicable or blood borne diseases, sexually transmitted diseases, and any other type of information that is given special privacy protection under state or federal laws. This consent includes Headlight Health obtaining and sharing your health information from health information exchanges (HIE) and similar services for purposes of treatment, payment, health care operations, and public health, and using your health information to create de-identified health information.

17. You understand that you have the right to withhold or withdraw your consent to the use of telehealth at any time, without affecting your right to future care, if available. You may revoke your consent in writing at any time by contacting Headlight Health or your Provider.

18. Either you or the Provider may terminate your relationship at any time. If the relationship is terminated, your Provider may give you other provider recommendations, if requested.

STATE-SPECIFIC DISCLOSURES