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Group Therapy Consent

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Limited HIPAA and 42 CFR Part 2 TelehealthConsent and Authorization for Group Therapy

Ethos Behavioral Health Group, LLC’s and its affiliates (“Ethos”) provide an option in appropriate circumstances for clients in group therapy to participate in their group via telehealth. This option will only be available if all the effected group participants agree to the below Authorization and Consent.

If you choose to participate in a group via telehealth, you agree as follows:

The undersigned client (“Client”) hereby gives Client’s consent and authorization to participate in Ethos Behavioral Health Group, LLC’s and its affiliates’ (“Ethos”) telehealth program.  While Ethos’ telehealth options, including Zoom, Facetime, and Cisco Web are privacy optimized, Ethos may not have formal business associates agreements in place with those services (and no such agreements are available with Facetime), which may create technical statutory privacy issues.  Client consents to those third party services acting as conduit for Client’s protected health information and potentially obtaining access to that information.  Client also understands that if Client is not in a private location while accessing telehealth, others may see or overhear Client’s protected health information.  Client thus hereby consents and authorizes Ethos to disclose Client’s protected health information to its telehealth providers or to anyone present with Client when Client accesses Ethos’ telehealth service to the extent necessary to use Ethos’s telehealth services for the purpose of Client’s treatment.  Client further agrees to waive all applicable federal and state privacy protections, including but not limited to HIPPA protections and protections under 42 CFR Part 2, to the extent necessary to participate in Ethos’ telehealth options as described above. This authorization will remain in place until revoked by Client.  Client may revoke this authorization at any time by contacting Ethos’ compliance officer at tlankau@ethosbhg.com or 832-457-5046. The terms of Client’s service with Ethos will not be affected if Client chooses not to sign this consent and authorization.
Client also agrees to the following to protect the confidentiality of the other members in the group that are participating in person or via telehealth:

  • Client agrees to access telehealth in a private, closed room where no other people are present and no other people can overhear the group discussions or see Client’s screen;
  • Client agrees not to record group discussions;
  • Client agrees not to use last names of group members or disclose any information that could be used to easily identify group members;
  • Client agrees and understands that Client’s telehealth session may be terminated at any time, and will be terminated if it appears there is a confidentiality issue;
  • Client agrees that all other group participants must consent to Client’s participation via telehealth, and that consent may be revoked at any time, which could result in the termination of the telehealth session without notice;
  • Client agrees that if technical issues prevent effective participation, the telehealth session may be ended, and that group discussions will not be interrupted to address technical issues.

If you choose to allow others in your group to participate in your group session via telehealth, you agree as follows:

The undersigned client (“Client”) hereby gives Client’s consent and authorization to the disclosure of their private health information to the extent necessary to allow members of their therapy group to participate in their group therapy via telehealth.  While Ethos’ telehealth options, including Zoom, Facetime, and Cisco Web are privacy optimized, Ethos may not have formal business associates agreements in place with those services (and no such agreements are available with Facetime), which may create technical statutory privacy issues.  Client consents to those third party services acting as conduits for Client’s protected health information and potentially obtaining access to that information.  Client also understands that if a fellow group member is not in a private location while accessing telehealth, others may see or overhear Client’s protected health information.  Client thus hereby consents and authorizes Ethos to disclose Client’s protected health information to its telehealth providers or to anyone present with Client when Client accesses Ethos’ telehealth service to the extent necessary to allow a fellow group member to use Ethos’s telehealth services for the purpose of Client’s and Client’s fellow group members’ treatment.  Client further agrees to waive all applicable federal and state privacy protections, including but not limited to HIPPA protections and protections under 42 CFR Part 2, to the extent necessary to allow Clients’ fellow group members to participate in Ethos’ telehealth options as described above. This authorization will remain in place until revoked by Client.  Client may revoke this authorization at any time by contacting Ethos’ compliance officer at tlankau@ethosbhg.com or 832-457-5046. The terms of Client’s service with Ethos will not be affected if Client chooses not to sign this consent and authorization.
Further, to protect all group members’ confidentiality, Client additionally agrees:

  • Not to mention last names of group members or information that would allow group members to be easily identified;
  • To inform the group leader if any time Client feels uncomfortable with other group members participating via telehealth, in which case the telehealth session will be ended.