Patient Agreement  

Consent To Examination And Treatment 

I understand that I may require medications, examinations, diagnostic procedures or other treatments in     connection with my condition. I hereby consent to the performance of such examinations, treatments, and procedures, as appropriate personnel deem necessary or advisable.  

I understand that the practice of medicine is not an exact science, and I acknowledge that no guarantees have been made to me as to the results of treatments or examinations in the hospital. 

I understand that I have the right to withhold consent to any medical procedure. I realize that if I withhold consent for a recommended procedure that treatment may be rendered partially or wholly ineffective. 

I understand that the visit may occur via secured video platform and there may be limitation due to this modality of medical practice that is different than in-person visits.  The benefits of telemedicine include improved access and more frequent visits while the limitations include incomplete physical examination.   

Personal Electronic Devices 

I understand that photographing, video/voice recordings of the doctor/provider is strictly prohibited, unless permission has been granted. 

Health Care Privacy 

The clinician who will be rendering services will adherent strictly to HIPAA practices.  The healthcare records will only be provided to me or my legally authorized representative, or for treatment or payment purposes only.    

Notice To Consumers 

Medical doctors are licensed and regulated by the Medical Board of California (800) 633-2322; www.mbc.ca.gov. 

Right To Advance Directives 

I have been given written information on my right to make medical decisions and to have advance directives (in the form of a living will or Durable Power of Attorney for Health Care). I understand that it is my responsibility to provide the clinician with a copy of my advance directive, and that failure to do so may mean my wishes are not known to my providers. I understand that my advance directive will be handled with appropriate sensitivity and confidentiality and that I will be provided with the same quality of care whether or not I have an advance directive. 

Acknowledgment 

I certify that I have read the above and it has been explained to me so that I understand. I certify that I am the patient the parent/guardian of the patient or am duly authorized by the patient as his/her general agent to review the above and to accept its' terms.  

Privacy Policy 

Last Updated: 10/20/2024 

1. Introduction

Welcome to Asynchealth ("we," "us," or "our"). Your privacy is important to us, and we are committed to protecting your personal information. This Privacy Policy explains how we collect, use, disclose, and safeguard your data when you access or use our website, mobile application, or any other products and services provided by us (collectively, the "Services"). Our full Privacy, Use and Disclosure Policy is available on request. 

By accessing or using our Services, you consent to the practices described in this Privacy Policy. If you do not agree with the terms of this Privacy Policy, please do not use our Services.  

2. Information We Collect  

2.1 Personal Information 

We may collect personal information that you voluntarily provide to us when you use our Services, including but not limited to:  

Name  

Email address  

Phone number  

Address  

Payment information (if applicable)  

2.2 Usage Data  

We may automatically collect certain information about your use of our Services, including:  

IP address  

Device information (e.g., device type, operating system)  

Browser type  

Usage statistics  

Clickstream data  

Cookies and similar technologies  

3. How We Use Your Information  

We may use your information for various purposes, including:  

Providing and maintaining our Services  

Personalizing and improving user experience  

Sending you updates, promotions, and marketing communications  

Processing payments (if applicable)  

Responding to your inquiries and providing customer support  

Complying with legal and regulatory obligations  

Developing improved services, clinical outcomes and analytics 

4. Disclosure of Your Information  

We may share your information with:  

Service providers and vendors assisting with the operation of our Services  

Legal authorities, when required by law or to protect our rights or the safety of others  

Third parties in connection with a business transaction, such as a merger, acquisition, or sale of assets 

5. Security  

We employ appropriate security measures to protect your data from unauthorized access, disclosure, alteration, or destruction. However, no method of transmission over the internet or electronic storage is entirely secure. Therefore, we cannot guarantee absolute security.  

6. Your Choices 

You have the following choices regarding your information:  

You may access, correct, or delete your personal information by contacting us.  

You may opt out of receiving promotional emails from us by following the instructions in those emails.  

You may set your browser to refuse cookies, but this may affect the functionality of our Services.  

7. Changes to this Privacy Policy

We may update this Privacy Policy from time to time to reflect changes in our practices or for other operational, legal, or regulatory reasons. Your continued use of our Services after such changes will constitute your consent to the revised policy.  

8. Contact Us  

If you have any questions or concerns about this Privacy Policy, please contact us at customer-data@asynchealth.com. 

ASYNCHEALTH HIPAA AUTHORIZATION  

By signing this HIPAA Authorization (the “Authorization”), I authorize and request my “Treatment Organization” to disclose the following limited health information to AsyncHealth, Inc. (“Async”) or for Async to collect such health information and provide it to Treatment Organization: all of my (or my child’s) name, contact information, audio, video, and photographic material taken of me, which shall include all of my health information disclosed during such interviews, which shall specifically include my mental health diagnosis or treatment information, substance abuse treatment information, HIV information, as applicable (together, the “Health Information”).  

If I decide to sign this form, I have the right to request that audio/video recording, filming, or photographing cease at any time.  

Purpose: 

I understand that the purpose of this Authorization is to allow Async to perform the interview services to provide to my Treatment Organization so I can receive care, and to allow Async to use such Health Information, in a de-identified, aggregated format to perform quality improvement, data analytics, machine learning, and algorithmic development to further analyze and develop Async’s products and services. I understand that my contact information will only be used for the purposes of Async, my Treatment Organization, or for payment purposes, and not otherwise disclosed to any other individual or entity. 

Accordingly, by signing this Authorization below, I hereby authorize Async to take and make use of my and/or my Health Information, which may include my sensitive mental health information, substance abuse treatment information, and/or HIV information for the Purpose described above.  

Acknowledgements: 

I understand that once my Health Information has been de-identified, in accordance with the Health Information Portability and Accountability Act of 1996 (“HIPAA”) requirements, it is no longer protected by HIPAA or subject to this authorization. 

I further understand that if the person or entity that receives my Health Information is not required to comply with applicable privacy regulations, then the Health Information described above may be re-disclosed by the recipient and is no longer protected by the HIPAA privacy rule. 

I understand that I do not have to grant this Authorization. I am accepting this Authorization voluntarily and I understand I am not restricted from receiving services from my Treatment Organization should I decide not to sign this Authorization. I further understand that my eligibility for benefits under my insurance plan may not be conditioned upon my acceptance of this Authorization. 

I hereby forever discharge, hold harmless and release Async from all claims, demands and causes of action which, I, my heirs, representatives, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this Authorization. I hereby release and forever discharge Async from any and all claims and demands arising ort of or in connection with the use of the Health Information in the development of any Asnyc products or services.  

Expiration 

I understand that this Authorization is in effect until I revoke it. 

Revocation Rights 

I further understand that I have the right to revoke this Authorization, in writing, at any time by sending notice to customer-data@asynchealth.com. I acknowledge and understand that the revocation will be effective immediately upon the Async’s receipt of my written notice; however, the revocation will not affect any uses or disclosures of the Health Information that were already made by Async prior to receipt of the written notice of revocation.  

DICLAIMER LANGUAGE TO BE INSERTED INTO PRODUCT  TO BE SEEN BY PATIENT BEFORE THEY START THE INTERVIEW 

ASYNCHEALTH, INC. IS NOT A PROVIDER OF CLINICAL CARE OR ADVICE. ASYNCHEALTH, INC. IS NOT PROVIDING YOU WITH ANY TREATMENT OR DIRECTLY RESPONSIBLE FOR YOUR CARE.  THE PRECORDED INTERVIEWER REPRESENTED BY ASYNCHEALTH, INC. IS NOT A CLINICIAN, IS NOT PROVIDING YOU WITH ANY TREATMENT, AND IS NOT DIRECTLY INVOLVED OR RESPONSIBLE IN YOUR CARE. BEFORE YOU TAKE ANY ACTION THAT MAY AFFECT YOUR HEALTH OR SAFETY, OR THE HEALTH OR SAFETY OF OTHERS, PLEASE CONSULT WITH A MEDICAL PROFESSIONAL.  IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY, CALL YOUR LOCAL EMERGENCY PHONE NUMBER OR YOUR HEALTH CARE PROVIDER IMMEDIATELY.  IF YOU ARE THINKING ABOUT SUICIDE, OR IF YOU ARE CONSIDERING TAKING ACTIONS THAT MAY CAUSE HARM TO YOU OR TO OTHERS, OR IF YOU FEEL THAT YOU OR ANY OTHER PERSON MAY BE IN ANY DANGER, OR IF YOU HAVE ANY MEDICAL EMERGENCIES, CALL 911 IMMEDIATELY AND NOTIFY ANY RELEVANT AUTHORITIES.  THE SUICIDE HOTLINE IS 988 OR 800-273-8255 IF FACED WITH AN IMMEDIATE OR EMERGENT CRISIS.  THERE ALSO MAY BE OTHER NATIONAL, REGIONAL, AND STATE RESOURCES AVAILABLE TO YOU.