Limited HIPAA and 42 CFR Part 2 TelehealthConsent and Authorization
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 Ehthos’ 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’ 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 firstname.lastname@example.org 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.