Before using this service, it’s important to make sure you understand how using the Brightside Health app, including native and web-based apps (“the App”) to obtain care differs from visiting a more traditional in-office medical practitioner. In particular, it is important that you understand the risks associated with taking antidepressant medication and participating in therapy, if applicable. If you have any questions, please send us an email at email@example.com, or a message using the chat feature offered through your Brightside patient portal.
This service is provided by Brightside Health, Inc (sometimes referred to as “Brightside”). BRIGHTSIDE HEALTH, INC. DOES NOT PROVIDE ANY MEDICAL OR PROFESSIONAL SERVICES. Brightside Health, Inc. 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 initiate a request for services through the App, Brightside Health will nominate one or more psychiatric providers and/or therapists, as applicable, licensed to practice in your state to provide care to you. These Healthcare Providers are third-party beneficiaries of this Agreement and are not employed or compensated by Brightside Health, Inc.
I understand that I should never use the App in an emergency. I understand that, in an 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/.
I understand that Brightside 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.
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.
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.
I give my informed consent to the use of telehealth by Healthcare Providers affiliated with Brightside Health.
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 if telehealth is a suitable forum for my treatment. 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 Brightside 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, 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.
I understand that by using the App and associated third party services, I’ll receive care for depression and/or anxiety along with related symptoms deemed treatable by my Healthcare Provider(s) through Brightside’s services. I understand that by using the App and associated third party services, I won’t receive any other medical or therapy services that go beyond depression and/or anxiety, and other symptoms related thereto. I understand that I need to seek services elsewhere for my medical or therapy needs not related to depression or anxiety, or as instructed by my Healthcare Provider(s).
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 antidepressant medications and/or other forms of prescribed treatment are safe for me.
With respect to both therapy and medical 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 understand that using telehealth means that 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.
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 provider-patient relationship.
I understand that, if I elect to use the App for medical services, I can request a prescription for different types of antidepressant medication, each of which has different risks of adverse events and different side effects. I understand that all the information I provide when requesting a prescription for antidepressant medication is important in the Healthcare Provider’s determination as to whether I’m a good candidate for a particular medication and for telehealth services in general. I agree to provide true and complete information and understand that if I provide information that isn’t true and complete, then I’ll be at greater risk of adverse events from taking antidepressant medication. My Healthcare Provider nor Brightside 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 adverse events can be caused by a number of things, including other health conditions I may have, allergic reactions, side effects, or interactions between antidepressant medication and 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 any medications or supplements that I am taking.
I understand that adverse events from taking antidepressant medication include but aren’t 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 can involve examining and addressing strong emotions that may be upsetting for me.
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 that I must regularly check my email for messages and the App for updates because this is the way that Brightside Health 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
I understand that if I have any non-urgent questions relating to my care, I can submit an inquiry to Brightside by emailing firstname.lastname@example.org, or by sending a message to Member Services located in the App. I understand that Brightside Health may not review my messages until the next business day, or possibly later.
I understand that by using the App, my Healthcare Provider is under no obligation to complete any documentation related to my workers’ compensation or disability claim statuses. 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 Brightside services with any intention of finding a Healthcare Provider to complete my workers’ compensation or disability claim documentation either now or in the future, I am responsible for notifying my Healthcare Provider of this intention during my initial consultation.
I understand that by using the App, I will receive personalized content on the most appropriate 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 that it is important that I read the information provided within the App and, when applicable, via links to third-party websites for information about my depression and/or anxiety treatment or therapy choices.
I acknowledge it is critical that I read and understand all information provided about any antidepressant medication prescribed to me, if applicable. I understand that some information about the risks of taking antidepressant medication can be found within the Frequently Asked Questions page on Brightside Health’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.
I understand that the electronic nature of the App means that there are inherent risks to the privacy of my health information, especially when comparing this form of care to a traditional “in-office” setting. I understand that although Brightside Health implements a wide range of administrative, physical, and technical safeguards to protect my health information, Brightside Health cannot affirmatively guarantee the privacy and confidentiality of my health information.
For more details about how Brightside Health protects my health information, see our Notice of Privacy Practices.
I understand the Healthcare Provider that Brightside 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.
I agree and authorize my Healthcare Provider to release my protected health information to Brightside Health and its affiliates.
I agree to this Consent to Telehealth and acknowledge that using the Site constitutes an on-going agreement to this Consent to Telehealth.
By providing information about your health insurance or health plan to Brightside, you are authorizing us to submit claims for covered Medical Services to your health insurer or health plan. Additionally, you hereby assign or otherwise authorize us to charge you, your health insurance plan, and/or another indicated payer for the Medical Services provided to you. You authorize the release of any medical or other information necessary to process any claims for the Medical Services provided. You further understand and accept your financial responsibility for any portion of the bill not covered by your health insurer or health plan. SUBMISSION OF CHARGES DOES NOT WAIVE OUR RIGHT TO SEEK PAYMENT DIRECTLY FROM YOU.