Enrollment Process for CBP

Notice of Privacy Practices and Release of Information Policies

Our Notice of Privacy Practices and Release of Information Policies provides information about how Endeavors Behavioral Health may use and disclose protected health information (PHI) about you. The clinic provides this form to comply with the Health Insurance Portability and Accountability Act (HIPAA) and when applicable 42 CFR Part 2.

The NPP contains a patient rights section describing your rights under the law. Please review the Notice of Privacy Practices thoroughly before signing this acknowledgement form. In the event that terms of the notice change, a revised copy will be made available to you.

This is a consent to participate in Virtual Care-based services with the Endeavors Wellness Program through a two-way audio/video link. I understand that certain hearing, visual, or cognitive deficits may limit the ability to communicate via a virtual care-based technology. I acknowledge that I am 18 years of age at the time of signing this consent.

The purpose of these services is to evaluate and treat my behavioral/mental health concerns with the staff at Endeavors Wellness Program. This care is governed by all the same protections and limitations as in person care (see HIPAA Acknowledgment Form Commitment to Treatment, and Request for Treatment and Informed Consent).

Discontinuation of the virtual session will occur:

• If I become a danger to self or others.
• If I am in immediate risk of suicide.
• If I am assessed to be impaired by intoxication.
• If my symptoms increase by the use of telecommunication technology, and/or are otherwise unable to participate in an audio/video platform.
• If I lack privacy and/or a safe environment in which I can participate in the session. Should any of these occur, my provider will take appropriate action to further assist me.

In the case of imminent risk, my provider will contact local emergency services and remain available to me and emergency services.

I understand the following:

1. The potential benefits of virtual care are increased access to care and convenience as related to barriers in my treatment to include but not limited to transportation limitations, living at a distance from the clinic, employment conflicts, or other reasons.
2. The possible risks are interruption/disconnection to the audio/video link, delay in treatment due to failure of equipment, internet connection that may fail, and the lack of other services that may be available in an in-person visit.
3. The virtual care platform is a secure video conferencing system. No information will be recorded and stored through the platform. Only my provider will have the ability to share their screen during session and will terminate each session upon completion.
4. An emergency contact plan will be completed during the test call to ensure that my provider has all of the contact numbers and address of my physical location in case of an emergency during our treatment time.
5. The provider I see will determine whether or not the condition being diagnosed and/or treated is appropriate for a virtual care-based encounter. If virtual care services are deemed inappropriate by my provider at any time, I will be offered a different follow-up plan.
6. Prior to my first virtual care session, my provider or another staff member will do a test call to ensure ability to connect through the virtual care platform, and that the software/equipment provides for a quality connection.
7. If the initial test call is unsuccessful and problems are not able to be resolved, my provider will call me and a decision to continue with virtual care will be determined at that time.
8. At the beginning of each virtual care session, my provider will do a location check with me to verify that I am in an appropriate location to conduct the session and document the address where I am located. I will provide/verify the phone number where I can be reached at the beginning of the session in case that connection is lost during session. I understand this information will be recorded in my electronic health record.
9. Information of session content will be documented by my provider in the agency Electronic Health Record (EHR) system that is HIPAA compliant. If at any time during session I feel my information is at risk, I need to work with my provider to address any privacy issues. I understand it is my responsibility to address concerns related to the privacy of my health information to include but not limited to where I am physically located during the session or indicate whether others are in close proximity.
10. I may request that virtual care-based services be discontinued at any time.
11. If I have an emergency outside of the session, I understand that I should call the clinic as soon as possible to request assistance with appointment.
12. If I have any questions before, during, or after the virtual care visit, I should contact the clinic.

Client Telecommunication Requirements

1. Personal computer/tablet/smartphone with internet connection with adequate bandwidth and processing power to run the virtual care platform.
2. Access to a Web camera, microphone and speakers.
3. Access to a private secure space where video and audio cannot be overheard or seen by others and at low risk for interruptions by others during session.
4. Access to a secure phone line (cell or landline) available during the session, if audio from computer/tablet/smartphone will not be used.

I hereby acknowledge and fully understand the potential dangers of voluntarily using a Endeavors wellness facility (to include “offsite offerings”) to include all the amenities therein such as: exercise equipment, exercise space, personal care facilities, communal spaces, wellness classes, wellness tools, wellness rooms (“Wellness Facility”). In addition, I further acknowledge and fully understand the potential dangers of voluntarily utilizing Endeavors virtual wellness programs, classes, or group activities (collectively, “Virtual Programs”) and collectively with Wellness Facility “Endeavors Wellness”. For the avoidance of doubt, Endeavors is not obligated to provide the above outlined services, facilities, amenities or programs.

ASSUMPTION OF RISK. I acknowledge and agree that (i) I am responsible for consulting with my physician or other health care providers prior to enrolling and utilizing the Fitness Center to determine whether participating in a Class is appropriate for me; (ii) I will not enroll in or participate any of the Endeavors Wellness offerings if my physician or health care provider advises against it; and (iii) if I experience faintness, dizziness, pain or shortness of breath at any time that I will stop immediately and contact my physician or health care provider. I further understand and acknowledge that my use of Endeavors Wellness offerings carries with it a risk of serious injury to me including permanent disability or death. I voluntarily assume any and all risks of injury, disability, or death caused by, or arising from, my use of the Endeavors Wellness offerings.

RELEASE OF CLAIMS: I HEREBY EXPRESSLY WAIVE AND RELEASE ANY AND ALL CLAIMS, NOW KNOWN OR HEREAFTER KNOWN AGAINST ENDEAVORS ITS OFFICERS, MANAGERS, EMPLOYEES, CONTRACTORS, AGENTS, VOLUNTEERS, INSURERS, AFFILIATES OR RELATED ENTITIES, ITS PROGRAMS (INCLUDING THE VETERANS WELLNESS CENTER), MEMBERS, SUCCESSORS, AND ASSIGNS (COLLECTIVELY, "RELEASEES"), ON ACCOUNT OF ILLNESS INJURY DISABILITY DEATH OR PROPERTY DAMAGE ARISING OUT OF OR ATTRIBUTABLE TO MY USE OF THE VWC, THE FITNESS CENTER OR PARTICIPATION IN A PROGRAM, WHETHER ARISING OUT OF ORDINARY NEGLIGENCE OF THE RELEASEES OR OTHERWISE. I COVENANT NOT TO MAKE OR BRING ANY SUCH CLAIM AGAINST THE RELEASEES AND FOREVER RELEASE AND DISCHARGE THE RELEASEES FROM LIABILITY UNDER SUCH CLAIMS.

INDEMNIFICATION. I AGREE TO INDEMNIFY, DEFEND AND HOLD HARMLESS ENDEAVORS AND THE RELEASEES AGAINST ANY AND ALL LOSSES DAMAGES LIABILITIES DEFICIENCIES CLAIMS ACTIONS JUDGMENTS SETTLEMENTS INTEREST AWARDS PENALTIES FINES COSTS OR EXPENSES OF WHATEVER KIND INCLUDING ATTORNEY FEES THE COSTS OF ENFORCING ANY RIGHT TO INDEMNIFICATION UNDER THIS AGREEMENT AND THE COST OF PURSUING ANY INSURANCE PROVIDERS ARISING OUT OR RESULTING FROM ANY CLAIM OF A THIRD PARTY RELATED TO MY USE OF THE FITNESS CENTER OR PARTICIPATION IN THE CLASSES INCLUDING ANY CLAIM RELATED TO MY OWN NEGLIGENCE OR THE ORDINARY NEGLIGENCE OF ENDEAVORS.

I HAVE READ AND FULLY UNDERSTAND THIS RELEASE AS SET FORTH ABOVE AND UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT. I CERTIFY THAT I HAVE REACHED THE AGE OF MAJORITY AND HAVE SIGNED UNDER MY OWN FREE WILL. IF I HAVE NOT REACHED THE AGE OF MAJORITY, I UNDERSTAND THAT MY PARENT OR GUARDIAN CONSENT TO THESE TERMS ARE REQUIRED. NO EXCEPTIONS. I FURTHER CERTIFY THAT I AM SUFFERING UNDER NO DISABILITIES/IMPAIRMENTS/MEDICAL CONDITIONS OR PREVIOUS INJURIES THAT WOULD PREVENT MY SAFE UTILIZATION OF THE FITNESS CENTER OR CLASSES.