Informed Consent for Treatment

Including Patient Rights and Responsibilities

Last updated: September 3, 2024

If you have any questions about this consent or obtaining treatment through KMR Therapy, please send us an email at support@kmrtherapy.com.

This service is provided by KMR Therapy Health, Inc (sometimes referred to as “KMR Therapy”). KMR Therapy HEALTH, INC. DOES NOT PROVIDE ANY MEDICAL OR PROFESSIONAL SERVICES. KMR Therapy offers native and web-based apps (“the App”) that can store a request for medical and/or therapy services and forward that request to a licensed psychiatric provider or therapist (individually referred to as a “Healthcare Provider”), as applicable. After You (the patient or parent/legal guardian of the patient) initiate a request for services through the App, KMR Therapy Health will display information pertaining to one or more psychiatric providers and/or therapists, as applicable, licensed to practice in your state to provide care to you and help you engage in care with your selected Healthcare Provider(s). These Healthcare Providers are third-party beneficiaries of this Agreement and are not employed or compensated by KMR Therapy Health, Inc.

KMR Therapy will never discriminate or provide disparate treatment on the basis of race, color, national origin, age, marital status, sex, sexual orientation, gender identity, gender expression, disability, religion, or veteran status.

Your Rights

As a patient or a patient’s legal representative, you have the right to:

• Participate in care at your sole discretion. You have the right to refuse or withdraw consent at any time, which will cause you to be discharged from the KMR Therapy Health platform and care. You will not be subjected to any form of coercion or undue influence in making your decision.
• Receive considerate, respectful, and private care in a safe and secure virtual environment.
• Receive complete information about your diagnosis, treatment options and alternatives, risks, and prognosis communicated to you in a clear and understandable manner. You are encouraged to ask questions and discuss any considerations or concerns with your healthcare provider.
• Speak up to identify any uncomfortable situations or confusion about the care provided or planned, or if you have any safety concerns related to your treatment.
• Know the name and professional status of those with whom you interact and change providers if other qualified providers are available.
• Expect confidentiality of your medical record and billing information to the extent provided by law, which is detailed in KMR Therapy’s Notice of Privacy Practices.
• Request that a copy of your medical record be provided to you or a third-party.
• Request an explanation of all billing charges, payment policies, and billing procedures.
• Expect a timely resolution of your health care and/or billing concerns.
• Receive disclosure if you are referred to entities which KMR Therapy has a financial interest in.
• Submit a complaint, concern or feedback regarding care or service without fear of reprisal or discrimination by communicating directly with a staff member, which can be done by sending a message to Member Services through your Member Portal, or emailing Member Services at support@kmrtherapy.com.

If you believe that KMR Therapy has violated any of these rights or other civil rights which you are entitled to, you may submit a complaint to the Department of Health & Human Services. Information for submitting such complaints may be found on the Department’s Complaints & Appeals page.

Acknowledgements

By using the telehealth services available through the App, I (the patient or parent/legal guardian on behalf of the patient) acknowledge the following:

Not For Emergencies

I understand that I should never use the App in an emergency. I understand that, in a psychiatric or medical emergency, I should dial 911 or go to an emergency department.

I understand that 24-hour help is available through the Crisis Text Line at 741-741, or the Suicide Prevention and Crisis Lifeline by calling or texting 988, or visiting https://988lifeline.org/.

Telehealth Risks

I understand that KMR Therapy provides a telehealth platform, and that telehealth involves the delivery of healthcare services using different forms of electronic communications and information technology between a Healthcare Provider and a patient who are not present in the same physical location.

If I choose to use telehealth services, I understand this means that a Healthcare Provider is unable to conduct certain tests or assess my vital signs in-person, which may in some cases prevent the Healthcare Provider from providing me with a diagnosis or treatment, or from identifying my need for emergency medical care or treatment.

In some instances, my Healthcare Provider may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled telehealth consult or a meeting with my local primary care provider.

I understand that while the use of telehealth may provide potential benefits to me, as with any health care service, no such benefits or specific results can be guaranteed. My condition may not be cured or improved, and in some cases, may get worse.

Provider-Patient Relationship

I give my informed consent to the use of telehealth by Healthcare Providers through the App.

I understand that the Healthcare Provider has the right to refuse to take responsibility for my care if the Healthcare Provider, in their professional judgment, believes that I am not a good candidate for this telehealth service. I understand that making a request for treatment (e.g. by completing the intake questionnaire, scheduling a consultation, and/or making payment) does not in and of itself create a duty of care for the Healthcare Provider, nor does it establish a provider-patient relationship.

I understand that the Healthcare Provider will take responsibility for my care only after the Healthcare Provider has reviewed my request for treatment, the information I provide during the registration and intake processes, AND completes my initial patient consultation. Only after this consultation is completed will my Healthcare Provider be able to determine which treatment and modality is suitable for me. I understand that the provider-patient relationship and the duty of care owed to me by my Healthcare Provider as a result of this relationship will not be established until after all parts of this process are completed.

I understand that, at any time during my care, my Healthcare Provider may determine that telehealth services are no longer appropriate for me, refuse to take further responsibility for my care, and/or refer me to an appropriate in-person care facility. I understand that if my relationship with the Healthcare Provider ends, regardless of reason, that the duty of care afforded to me through the provider-patient relationship shall no longer exist.

I understand that there may be a delay until the next business day, and at times longer, before a Healthcare Provider reviews my request for treatment and/or any messages I send.

I understand that I need to be responsive to ongoing requests from my Healthcare Provider and the information they request of me, including but not limited to completion of ongoing assessments about my symptoms, functioning, and/or side effects during my treatment, responding to messages, and scheduling follow up consultations, in order to remain under the care of my Healthcare Provider. If I am not responsive to these requests for information, or if I furnish only partial or misleading information, I understand that I shall not be considered to be under the care of my Healthcare Provider and that certain functionality may be unavailable to me until I complete the required follow-ups.

I understand that I must show respect to my Provider and other members of the KMR Therapy staff with whom I may interact. I understand that KMR Therapy will not tolerate verbal abuse, including profanity, discriminatory language, or threatening language toward any KMR Therapy employee or associated Provider and may result in the termination of care.

Care for Mental and Emotional Health Disorders Only

I understand that by using the App and associated third party services, I’ll receive care only for mental and emotional health disorders deemed treatable by my Healthcare Provider(s). I understand that by using the App and associated third-party services, I’ll receive treatment solely for the aforementioned disorders, and that I’ll need to seek services elsewhere for my medical, mental, or emotional health needs unrelated to those approved for treatment by my Healthcare Provider(s), or as instructed by my Healthcare Provider(s).

Greater Reliance On Information I Provide

I understand that, if I elect to use the App and associated third party services for medical services provided by a licensed Healthcare Provider, I seek to enter into a relationship where the Healthcare Provider relies exclusively upon information that I provide to decide whether or not certain medications and/or other forms of prescribed treatment are safe for me.

I understand that all information I provide when being considered for a treatment is important in the Healthcare Provider’s determination as to whether I’m a good candidate for a particular medication, treatment, and for telehealth services in general. With respect to therapy, Crisis Care, Intensive Outpatient Program, and psychiatry services offered through the App and associated third party services, I understand that the Healthcare Provider may have no way of verifying the information I provide, and that the Healthcare Provider will consider the information I provide to be accurate, true, and complete. Therefore, I attest that all information I communicate to my Healthcare Provider will be, to the best of my knowledge, entirely accurate and complete. I agree to provide true and complete information and understand that if I provide information that isn’t true and complete, I may be at a greater risk of experiencing an adverse event from taking medication or participating in therapy, Crisis Care, or IOP.

Neither my Healthcare Provider nor KMR Therapy shall ever be held liable for adverse circumstances that result in whole or in part because I provided untrue or incomplete information to my Healthcare Provider. I also understand that providing information that isn’t true and complete is cause for my Healthcare Provider to discontinue treating me.

I understand that using telehealth means the information transmitted to the Healthcare Provider may not be sufficient to allow for appropriate medical or therapy decision making by the Healthcare Provider, in which case the Healthcare Provider will notify me that I’m not an appropriate candidate for telehealth services.

Adhering to the Treatment Plan

I understand that it’s important to follow the treatment plan specified by my Healthcare Provider, which may include taking medication as prescribed and/or completing therapy sessions, and performing any homework or other requests my Healthcare Provider asks of me. I understand that not complying with instructions from my Healthcare Provider may limit the effectiveness of my treatment and ultimately serve as grounds for my Healthcare Provider to stop offering care to me, thereby terminating the patient-provider relationship. I agree to report promptly to my Provider any worsening conditions or any unexpected reaction to a medication.
I understand that it’s important for me to show up to my scheduled appointments and, when necessary, to follow the cancellation policy.

Understanding The Risks and Benefits Associated With Your Care

I understand that, if I elect to use the App for medical services, the care I receive may include certain risks. I agree to provide true and complete information and to discuss any risks associated with treatment options with my Healthcare Provider.

I acknowledge that proceeding with any potential care is my own choice based on weighing the associated risks and potential benefits.

I understand that treatment options available through KMR Therapy aim to provide mental health support to help patients achieve their treatment goals, reduce symptoms, and improve their overall quality of life. Potential benefits of mental health treatment include reduction in symptoms associated with depression, anxiety, or other mental health conditions, improved daily functioning, and enhanced ability to live your life according to your goals and priorities.

I understand that adverse medication events can be caused by a number of factors, including other health conditions I may have, allergic reactions, taking an incorrect dosage, side effects, or interactions between other medications, nutritional supplements, or other things I’m taking, and that it is my responsibility to make my Healthcare Provider immediately aware of any updates or changes to my health status, or to any medications or supplements that I am taking.

I understand that possible adverse events from taking antidepressant medications include but are not limited to, increased risk of suicide, Serotonin Syndrome, gastrointestinal bleeding, mania, birth defects, angle-closure glaucoma, seizures, hyponatremia, and heart, liver, or kidney issues.

I understand that participating in therapy, IOP, or Crisis Care can involve examining and addressing strong emotions that may be upsetting for me.

I understand that there are alternatives to these treatments that could also provide relief for my symptoms. Everyone experiencing a mental health condition should pursue lifestyle and behavior related opportunities to reduce symptoms, including appropriate exercise, healthy sleep, healthy diet, stress management, relationship building, resilience building, and more. These can be found through self help books, support groups, and a range of apps. Certain nutritional supplements may also help reduce mental health symptoms and enhance feelings of wellbeing. Patients are encouraged to explore these options and discuss them with their Healthcare Providers to determine the most suitable approach for their mental health and wellbeing.

Communication

I understand that by using the App, I won’t speak to or send and receive messages with a Healthcare Provider in real time, except in cases where a live video consultation is explicitly scheduled and confirmed.
I understand that my Healthcare Provider will endeavor to respond to messages within twenty-four (24) hours on weekdays, but that at times this may take longer.

I understand I am responsible for regularly checking my email and the App for messages, because the platforms will serve as the primary means through which my Healthcare Provider(s) and KMR Therapy will communicate important information to me. I understand that if I don’t regularly monitor my email and the App, then my care may be delayed and/or I may not receive important communications sent to me.

By providing my telephone number, I give permission for KMR Therapy Health to send me text messages or call me about reminders and updates related to my care.

I understand that if I have any administrative questions relating to my care, I can submit an inquiry to KMR Therapy by emailing support@kmrtherapy.com. I understand that KMR Therapy may not review my messages until the next business day, or possibly later.

No Controlled Substances

I understand that Healthcare Providers I may access through KMR Therapy Health do not prescribe controlled substances, including medications deemed by the DEA to have addictive properties or potential for abuse and outlined in DEA’s drug schedules. These include, but are not limited to, stimulant medications commonly used to treat ADHD (e.g. Ritalin, Adderall) and sedatives (e.g.Xanax, Ativan).

Accommodation Requests

I understand that by using the App, my Healthcare Provider is under no obligation to complete any documentation related to my accommodation requests. If I make any such request of my Healthcare Provider, I understand that my Healthcare Provider has the unequivocal right to determine in their sole clinical judgment whether they can furnish such information on my behalf. I understand that if I register for KMR Therapy services with any intention of finding a Healthcare Provider to complete an accommodation request either now or in the future, I am responsible for notifying my Healthcare Provider of this intention during my initial consultation.

Furthermore, I acknowledge that my Healthcare Provider may only complete documentation pertaining to my Family and Medical Leave Act (FMLA) and/or short-term disability status(es). Under no circumstances shall my Healthcare Provider be permitted to complete documentation as it relates other types of accommodations including, but not limited to, the following matters:

• Long-term disability;
• Permanent disability;
• Emotional support animals;
• Workers’ compensation; or
• Court ordered evaluations.

Understanding Telehealth Services

I understand that by using the App, I will receive personalized content on treatment or therapy methods available to me, and that this information is being provided so that I may make my own decisions about which treatment(s) or therapies I would like to pursue. I understand it is of the utmost importance that I read the information provided within the App and, when applicable, via links to third-party websites for information about treatment.

I acknowledge it is critical that I read and understand all information provided about any medication prescribed to me, if applicable. I understand that some information about the risks of taking medication can be found within the Frequently Asked Questions page on KMR Therapy’s website, and the information my Healthcare Provider notifies me of when I am prescribed a specific medication. I also understand that I should discuss prescribed medication, and any questions I have about it, with my Healthcare Provider or pharmacist before I begin taking it and that I should read all related Food and Drug Administration (“FDA”) notices and packaging inserts.

Use of technology

I understand and acknowledge that by using the App, KMR Therapy and my Provider may make use of technology to facilitate clinical documentation and other aspects of my care, including but not limited to transcription and analysis to support quality, safety, and efficiency. At all times KMR Therapy will manage and protect data consistent with regulatory guidelines and Privacy Practices.

Risk to Electronic Health Information

I understand that the electronic nature of the App means there are inherent risks to the privacy of my health information. I understand that although KMR Therapy implements a robust offering of administrative, physical, and technical safeguards to protect my health information, KMR Therapy nor my Healthcare Provider(s) can affirmatively guarantee the privacy and confidentiality of my health information.
For more details about my rights as it pertains to my personal health information, see our Notice of Privacy Practices.

I understand the Healthcare Provider(s) that KMR Therapy connects me to may share information regarding my health status with other medical professionals involved in my treatment, payer sources such as my health insurance group, and other organizations designated to facilitate healthcare operations.

Assignment of Benefits

By providing information about my health insurance or health plan to KMR Therapy, I am authorizing KMR Therapy to submit claims for healthcare services, rendered to me by my Healthcare Provider(s), to my health insurer or health plan(s), and agree that KMR Therapy or the relevant contracted Professional Corporation shall be directly reimbursed by my health insurance or health plan for the provision of these services. I also authorize KMR Therapy to release any medical or other information necessary to process claims for the provided healthcare services. I acknowledge that it is my responsibility to understand what my health insurance covers and which portions of care may be my responsibility. I understand and accept my financial responsibility for any portion of the fee for treatment not covered by my health insurer or health plan and authorize KMR Therapy to automatically charge my credit card for these fees.

Informed Consent for Treatment

I (the patient or parent/legal guardian of the patient) acknowledge that I have read and understood the above information regarding the services provided by KMR Therapy Health. I understand the potential benefits and associated risks, the nature of the treatment proposed, and the alternatives available to me. I understand and acknowledge patient rights and responsibilities associated with receiving treatment through KMR Therapy.
I understand that participation in the proposed treatment is entirely voluntary and that I have the right to refuse or withdraw consent at any time without affecting my right to future care or treatment. I also acknowledge that I have had the opportunity to ask questions and have received answers to my satisfaction.

I consent to the use of telehealth services for my mental health care and authorize KMR Therapy Health and its associated Healthcare Providers to provide treatment to me. I acknowledge that my continued use of the Site constitutes an ongoing agreement to this Informed Consent for Treatment.

Reporting Safety Concerns to the Joint Commission

You can report safety concerns to The Joint Commission online, by mail, or by fax:
Online: Visit the Joint Commission website and use the “Report a Patient Safety Event” link in the “Action Center”. The Joint Commission prefers this method because it allows for more direct and timely review of concerns.

By mail: Send your report to The Office of Quality and Patient Safety, The Joint Commission, One Renaissance Boulevard, Oakbrook Terrace, IL 60181. Your report should include the healthcare organization’s name, street address, city, and state. You can also choose to submit your report anonymously, or provide your personal information to know the status of your submission.

By fax: Fax your report to 630-792-5636