Consent to Telehealth

Please review and sign this Consent to Telehealth form prior to requesting any of the services provided by the Tava Health, Inc. (“Tava Health”) Application (the “Application”), our website at www.tavahealth.com, and our service providers (“Providers”) (collectively, the “Services”).

TREATMENT INFORMATION
Psychotherapy

Psychotherapy, or talk therapy, is a form of treatment that can be helpful for a variety of problems and challenges; however, therapy is not guaranteed to work for everyone. The specific process of psychotherapy will vary based on a number of factors including the particular problems or challenges addressed, the personalities of the therapy Provider and client, and other factors. Participation in psychotherapy can result in a number of benefits to you, including improved mood, improved interpersonal relationships, positive personal change, as well as resolution of specific problems and challenges. Psychotherapy often involves discussing unpleasant aspects of your life and can, at times, lead to distress or intense feelings such as anger, guilt, anxiety and frustration. These distressing aspects are generally temporary but should be discussed with your therapist. Your therapy Provider will guide you through the therapy process by providing support, establishing goals, providing treatment recommendations, and monitoring your progress.

Medication Management
Medication may be advisable (often in addition to psychotherapy) when the symptoms you are experiencing are not responsive to psychotherapy alone. Medication may offer relief when symptoms impede your ability to work, maintain relationships or care for your basic needs; however, medication is not guaranteed to work for everyone, including for those in these circumstances. Because medication treatment requires adherence to dosage and frequency and abstinence from alcohol or other non-prescribed substances, medication may not be appropriate for everyone. Medications have different risks of adverse events and side effects that range in severity and may be potentially life-threatening. If you fail to provide true and complete information to your prescriber, then you will be at greater risk for adverse events. Your prescribing Provider will discuss risks and benefits, side effects, and alternative treatments with you. Close follow-up with your prescribing Provider and communication about side effects or any medication changes is strongly recommended. Medication management may not be available to you through the Application, and you may be referred to another provider or encouraged to seek such services elsewhere.

CONSENT TO TELEHEALTH CARE
Telehealth involves the use of telehealth questionnaires, audio, video, or other electronic communications by your health care Provider for the purpose of interacting with you, consulting with you and/or other health professionals responsible for your care, and/or reviewing your medical information for the purpose of diagnosis, therapy, follow-up, and/or education. During your telehealth consultation, details of your medical history and personal health information may be discussed with you or other health professionals through the use of interactive audio, video, or other telecommunications technology. Additionally,  other treatment steps may take place and audio, video, and/or photo recordings may be taken and used during the course of such treatment and/or subsequent treatment. Electronic systems used during your telehealth encounter will incorporate network and software security protocols to protect the privacy and security of your health information, and will include measures to safeguard your data to ensure its integrity against intentional or unintentional corruption.

Anticipated Benefits of Telehealth Care
Improved access to health care services, by enabling you, the patient, to remain in your location while the health care provider may provide care to you from a distant site;More efficient medical evaluation and management;More convenient care scheduling and logistics;The opportunity to obtain expertise from a distantly located specialist; Enabling ongoing care and follow-up communication with a health care provider.

Potential Risks of Telehealth Care
As with any type or form of health care treatment, there are potential risks associated with the use of telehealth. These risks include, but may not be limited to:
Delays in medical evaluation / treatment could occur due to deficiencies or failures of the electronic equipment; In rare cases, information transmitted may not be sufficient (e.g. poor connectivity) to allow for appropriate medical decision making by care providers; In rare instances, security protocols could fail, causing a breach of privacy of your personal medical information; In rare cases, a lack of access to all of your medical records may result in adverse drug interactions or allergic reactions or other judgment errors;In some cases, it may be difficult for providers to track your location and guide your care in emergency situations.

Your Location During Video Consultations:
Providers are licensed to offer services on a state by state basis. In order to ensure your Provider is appropriately licensed, you agree to search for a Provider based upon your planned location at the time your consultation takes place. If your location changes at any point from one state to another, please let your Provider know as soon as possible. Please be aware that your Provider may not be able to provide services when you travel to a different state or country.

Missed Appointments and Cancellations:
Tava Health requires at least 24 hours advance notice for cancelation of an appointment. If you are unable to attend your scheduled appointment due to circumstances beyond your control, please reschedule your appointment to a more suitable time by using the Application as soon as possible. Once an appointment is scheduled, you will be expected to attend unless you reschedule. Tava Health reserves the right in its sole discretion to charge you with a cancelation processing fee of up to $150 in the event that you miss a scheduled appointment without providing prior notice of cancelation at least 24 hours in advance. Failure to provide sufficient notice for cancelations and/or repeated no-shows for your appointment(s) may impact your ability to schedule additional appointments with your Provider. Scope of Services: Tava Providers do not make recommendations, write letters of recommendation, or complete applications for services that are outside the scope of your individual treatment. This includes, but is not limited to, requests for medical leave, medical disability, fitness to work, child custody, or emotional support animals.

NOT FOR EMERGENCIES
I understand that I should never use the Services in the event of an emergency. Further, I understand that, in the event of an emergency, I should immediately dial 911 or go immediately to an emergency department.

I understand that if I experience an emergency during a telehealth consultation, or if my Provider becomes concerned about my personal safety, the possibility of me injuring someone else, or about me receiving proper care, my Provider and Tava Health will do whatever possible within the limits of the law to prevent me from injuring myself or others and to ensure that I receive the proper medical care. For this purpose, Tava Health or my Provider may contact the person whose name I have provided as my emergency contact.

By providing my consent on this Consent to Telehealth form, I, the patient, understand and agree to the following:

While I may expect the anticipated benefits from the use of telehealth in my care, no results can be guaranteed.

The federal and applicable state laws that protect the privacy and security of my health information apply to telehealth, and no information obtained in the use of telehealth care which identifies me will be disclosed to researchers or other entities without my authorization.

I have the right to withhold or withdraw my consent to the use of telehealth care in the ongoing course of my care at any time.

Subject to applicable law, I have the right to inspect all information obtained and recorded in the course of a telehealth interaction, and I may receive copies of this information for a reasonable fee.

A variety of alternative methods of medical care may be available to me, and I may choose one or more of these at any time.

My Provider may determine that telehealth services are not the best fit for me and, accordingly, may refer me to another provider.

Telehealth may involve electronic communication of my personal medical information to other health care providers who may be located in other areas, including outside of the state in which I reside.

I may need to provide photo-identification and my physical location to allow for accurate and effective care to be delivered.

I understand that I should never use the Services in the event of an emergency. Further, I understand that, in the event of an emergency, I should immediately dial 911 or go immediately to an emergency department.

I agree to provide full, true and complete information, including my age, my location and all my answers to health questions, and I understand that failing to do so may result in treatment that is not necessary, safe, or appropriate

It is my duty to inform my Tava Health Provider of any interactions regarding my care that I may have with other health care providers.

I consent to receive protected health information via email or SMS text messaging and I understand that messages shared through these communication channels may not be secure in every instance.

By continuing, I, the patient, hereby:
- Represent that I have read this Consent to Telehealth form carefully, and that I understand the anticipated benefits and risks of the use of telehealth provided to me through the Services.

- Give my consent to the use of telehealth by Providers engaged through the Services.

You, the patient, understand that by clicking on the “I AGREE” button, you are agreeing to the terms set forth herein, and that such action constitutes a legal signature.