Required Notices and Consents

About Chrysalis Health

Chrysalis Health is a behavioral healthcare organization providing community-based and outpatient mental health, substance use, psychiatric, care coordination, and specialized treatment services for children, adolescents, adults, and families. Services are individualized, trauma-informed, culturally responsive, and focused on recovery, resilience, family stability, and community integration.

Accreditation, Licensure & Quality

Chrysalis Health has been accredited by the Council on Accreditation (COA) since 2004 and is committed to continuous quality improvement and evidence-based care. Services are delivered in compliance with applicable federal and state regulations, payer requirements, and accreditation standards. Our organization emphasizes clinical excellence, client-centered treatment, and measurable outcomes.

Service Area

Chrysalis Health serves communities in Florida, Ohio, through office-based, community-based, school-based, home-based, and telehealth services. Programs are available across multiple regions of the state, allowing individuals and families to access care in the setting that best meets their needs.

Outpatient Behavioral Health Services

Outpatient services provide assessment, treatment, and recovery support for children, adolescents, and adults experiencing mental health, substance use, co-occurring, or behavioral health challenges. Services include individual, family, and group therapy, psychiatric evaluation, medication management, telehealth, and specialized treatment programs. Evidence-based practices include CBT, TF-CBT, Motivational Interviewing, Motivational Enhancement Therapy, Parent Management Training, Cognitive Processing Therapy, and Parent Child Interaction Therapy.

STARRT Program

The Sexual Trauma and Risk Reduction Treatment (STARRT) Program provides specialized services for youth demonstrating problematic sexual behaviors. Treatment focuses on accountability, safety planning, healthy boundaries, family engagement, risk reduction, and long-term behavioral change.

Targeted Case Management

Targeted Case Management assists individuals and families with accessing medical, behavioral health, educational, housing, employment, financial, and community resources. Services include assessment, advocacy, service planning, care coordination, resource linkage, and ongoing support.

Community Action Treatment (CAT) Team

The CAT Team is an intensive community-based behavioral health program serving youth at risk of out-of-home placement. Multidisciplinary teams provide therapy, psychiatric services, crisis intervention, mentoring, family support, school advocacy, and care coordination in home, school, office, and community settings.

Comprehensive Behavioral Health Assessments (CBHA)

CBHAs provide comprehensive evaluations of a child's emotional, behavioral, developmental, social, and family functioning. Assessments help identify strengths, needs, treatment recommendations, service needs, and placement considerations.

Family Support Team (FST)

Family Support Team (FST) provides grant-funded behavioral health services to Broward County youth (21 years and under) and their families that experience high utilization of crisis stabilization services which increase the risk of family disruption and child out-of-home placement. Our Team consists of a Therapist, Case Manager, and Peer Specialist who work together with the youth and family via Face-to-Face meetings and/or Telehealth.

Our objectives are to: Provide family-centered services to promote connection and stabilization of the family unit. Decrease out-of-home placements and psychiatric hospitalizations. Strengthen the family and support systems to assist them to live successfully in the community and improve health, wellness, and functioning. Identify resources and assist with linkage to higher level of care if needed.

Juvenile Justice Services

Chrysalis Health partners with the Florida Department of Juvenile Justice to provide Mental Health and Substance Abuse (MHSA) and Intensive Community-Based Care for Youth (ICCY) services. Programs include clinical assessments, treatment planning, therapy, case management, crisis intervention, and community resource coordination using evidence-based practices such as CBT, TF-CBT, and Seeking Safety.

Referral Information

Referrals may be received from physicians, hospitals, schools, managed care organizations, child welfare agencies, juvenile justice agencies, community partners, family members, or through self-referral. Each referral receives a screening and assessment to determine eligibility and the most appropriate level of care.

Service Delivery Options

Services may be provided in office, in home, in school, in community settings, or through telehealth depending on client needs and program requirements. Flexible scheduling, including evening and weekend appointments, may be available.

Community Partnerships

Chrysalis Health collaborates with managed care organizations, hospitals, schools, community behavioral health providers, child welfare organizations, juvenile justice agencies, and other community partners to coordinate care and improve outcomes for the individuals and families we serve.

Crisis Support and Emergency Services

Clients enrolled in applicable programs receive information regarding crisis response and after-hours support. For medical emergencies or situations involving immediate risk of harm to self or others, individuals should call 911 or proceed to the nearest emergency department.

Commitment to Quality Care

Chrysalis Health is committed to delivering high-quality, evidence-based behavioral healthcare services that promote recovery, resilience, independence, and long-term success. We work collaboratively with clients, families, and community partners to ensure access to the right care at the right time in the least restrictive setting possible.

You can access the CONSENT TO RELEASE AND/OR OBTAIN PROTECTED HEALTH INFORMATION (PHI) through the Client Portal.

I understand that as part of my treatment and/or services, Chrysalis Health originates, records, and maintains health information and opinions about me describing my health history, symptoms, examination and test results, diagnosis, treatment/services and plans for future care ("Protected Health Information" or "PHI").

I understand that my medical information ("PHI") about my condition, treatment and/or services, which includes mental health and/or substance abuse/use content, cannot be disclosed beyond myself without written consent per Federal and State regulations including, but not limited to: Health Insurance Portability and Accountability Act of 1996 (HIPAA), Code of Federal Regulations (CFR) Title 42 Part 2 — Confidentiality of Alcohol and Drug Abuse Patient Records and Title 45 Parts 160, 162 and 164 — Security and Privacy, unless otherwise provided and only to such extent found in the referenced regulations. With that understanding and for the purposes of guiding, planning, and providing treatment and/or services,

By signing the Chrysalis Health Consent Form, I agree to Release Information to, or Obtain Information from, the person(s)/agency(ies) listed therein.

I am aware that I can limit my consent to specific parties or specific information or specific uses. I also understand that Chrysalis Health has the right to refuse to provide me with treatment/services if it disagrees with any limitations I, or my legal guardian, place on uses or disclosures of my PHI.

I am aware I have the right to receive a copy of my PHI by unencrypted e-mail. Please be aware that receiving PHI through unencrypted email has the risk of PHI being read or otherwise accessed by a third party while in transit.

Further, I understand that I may revoke my consent in writing at any time to the extent that Chrysalis Health has not already taken action in reliance thereon. When and if revoking my consent, I agree to send the writing to the attention of "Privacy Officer". Finally, I agree that I have been given a copy of Chrysalis Health's Privacy Notice and that I have had an opportunity to review and understand such notice before providing my consent to the terms of this agreement.

Financial Responsibility

I acknowledge that I am financially responsible for all charges incurred for services provided to me by Chrysalis Center LLC, d/b/a Chrysalis Health, regardless of insurance coverage. I acknowledge that it is my responsibility to provide accurate insurance information at all times including providing updated insurance cards, verifying coverage details, and promptly notifying of any changes. If inaccurate insurance information results in denied claims or uncovered services, I will be responsible for payment.

I authorize Chrysalis Health to bill and receive payment from my insurance company or other third-party payer for services rendered.

I understand that I am responsible for any deductible, co-payment, coinsurance, or non-covered services as determined by my insurance plan.

I understand that I will receive an Explanation of Benefits (EOB) from my insurance company outlining what services were billed by Chrysalis Health and that the EOB indicates my financial responsibility. I will receive an invoice with payment instructions from Chrysalis Health outlining the remaining balance, if any, and providing details of the services provided. I am also responsible for any bounced checks, and fees incurred by Chrysalis Health.

I agree to promptly pay any portion of the charges for which I am responsible.

Copayments are due when services are rendered. To facilitate this process, Chrysalis Health will contact me two (2) business days prior to my scheduled appointment to collect a co-payment, deductible, co-insurance, or outstanding balance.

Deductible/Co-insurance — a good-faith payment may be due at the time of service. Good-faith payment is an estimate of what you will owe. After insurance processes the claim, you will receive an invoice from Chrysalis Health outlining the remaining balance, if any, and providing details of the services provided. In the event Chrysalis Health is unable to collect the good faith payment or outstanding balance, the appointment may be cancelled or rescheduled until payment arrangements are made.

If you have any questions regarding your explanation of benefits, or the amount or extent of your coverage you should contact your insurance company promptly for clarification.

No-Show Fee — Commercial Insurance Clients Only

We understand that you may sometimes need to reschedule appointments. When we make your appointment, please understand we are reserving time for you to see a provider. This courtesy makes it possible to give the best service here at Chrysalis Health. If you need to reschedule an appointment, please call us as soon as possible in an emergency situation or call at least 24 hours in advance. If you do not attend your scheduled appointment, a $50 no-show fee will be charged. Appointments are considered a no-show after 15 minutes of non-attendance.

Privacy Notice

As a client of Chrysalis Health, you have the right to privacy and confidentiality of your medical record and service/treatment information, with a few limited exceptions described in this notice. This right to privacy and confidentiality is protected by Federal and State regulations including, but not limited to: Health Insurance Portability and Accountability Act of 1996 (HIPAA), Code of Federal Regulations (CFR) Title 42 Part 2-Confidentiality of Alcohol and Drug Abuse Patient Records and Title 45 Parts 160, 162 and 164-Security and Privacy, as well as by Chrysalis Health policy.

This notice describes in detail how Chrysalis Health protects and safeguards your right to privacy and confidentiality. Please review your rights carefully, and if you have any questions or concerns, call us using the information listed under “Questions and Concerns” of this notice. We will be happy to answer any questions you may have.

I. In General

It is the duty of Chrysalis Health to protect and safeguard your private and confidential service/treatment information and medical record information. This means that no person other than you is entitled to your service/treatment information or medical record information, with the few exceptions described below.

II. Exceptions; Who Your Information May Be Disclosed To

(a) You

Chrysalis Health must disclose your service/treatment information and medical record information to you. You can either review your service/treatment information and/or medical record information in person or request in writing to obtain access to your information, by calling for an appointment or writing to the Privacy Officer at Chrysalis Health (address and phone listed in Question and Concern section of this notice). Chrysalis Health will provide you with copies of your medical record and/or schedule an appointment for you to see your medical record within 14 days of receipt of the request.

(b) Your Legal Guardian

If you are (1) under 18 years of age and are not emancipated or (2) have been declared mentally incompetent by a Florida court, then it is your legal guardian who is entitled to your Privacy and Confidentiality rights and who has the ability to enforce these rights. Your legal guardian also has the right to access all service/treatment information disclosure made by you, to such extent found in the referenced Federal and State regulations.

Where there is such legal guardian, in order to protect the confidentiality of therapy disclosures as well as to encourage such disclosures which enhance treatment, we will ask the legal guardian to give us written permission to maintain your confidentiality of therapy disclosures unless you are at risk of imminent harm.

(c) For Service/Treatment Purposes, With Your Consent

From time to time, we may need to use, disclose, or obtain documented information about you for the purposes of better providing you with evaluation, counseling, referrals and other services. Some, but not all of the information that may be obtained or shared with another provider includes assessments, evaluations, discharge summaries, medical documents, educational reports, etc., but not including progress notes which will not be shared with another provider for service/treatment purposes.

Additionally, at times we will need to communicate verbally with others about your service/treatment. Such communication regularly occurs between the treatment team, which includes the therapist, psychiatrist, supervisor, the counselor, case manager, and any other agencies and parties involved, such as the Department of Children and Families, the school or child care center, other mental health and social service providers, and/or case managers. Other times, you may want us to communicate with your family members as to your service/treatment.

Prior to any documented information being obtained or disclosed, or any verbal communications being made, Chrysalis Health will obtain your written consent to release or obtain that specific information to each party to whom we release information. Without such written consent, no documents will be obtained or disclosed and no verbal communications will occur.

(d) For Health Care Operations, With Your Consent

Chrysalis Health may at times be required to use and disclose your Protected Health Information (PHI) to another agency for purposes such as billing, payment, contracting, authorizing, accrediting, auditing, reviewing, quality improvement, billing, payment or other related health care operation purposes. Protected Health Information includes data such as your name, social security number, date of birth, address and other identifying information.

At the start of service/treatment, we will ask that you give us your consent to release your PHI for the purposes discussed in the previous paragraph. This one consent will cover all such release of PHI for health care operations purposes until your discharge, but you can limit and/or revoke your consent in writing at any time (see the Questions and Concern section of this notice below).

Additionally, when releasing your PHI for health care operations purposes, Chrysalis Health will only release information to the minimum extent necessary to accomplish the purpose of the release. Further, prior to Chrysalis Health releasing any of your PHI for health care operation purposes, Chrysalis Health will ensure that an agreement between Chrysalis Health and the other entity is in place, where the other entity agrees to provide you with the privacy and confidentiality protections required by law and by our agency.

(e) For Health and Safety

At times, Chrysalis Health may need to use and disclose your service/treatment information and medical record information to avert a serious and imminent threat to your health or safety or the health or safety of others. When releasing your information under these circumstances, such information will be released only to the minimum extent necessary to avert the threat. When reasonably possible, Chrysalis Health will attempt to obtain your written consent prior to the release of such information, but does not guarantee that such attempt to obtain consent will be made.

Additionally, Florida law requires Chrysalis Health to report to the Abuse Hotline any suspected child or elderly abuse, neglect, or abandonment. Florida law also requires that we report suspected domestic violence. Furthermore, in circumstances of clear and immediate probability of physical harm to a client or others, Chrysalis Health has a duty to warn the potential victim, the appropriate family member, law enforcement and other appropriate authorities, as required by Florida law.

(f) When Required to Disclose by Law

Chrysalis Health may disclose your service/treatment information and medical record information to the minimum extent necessary when we are required to do so by law, for the purposes of the federal or state regulating body ensuring Chrysalis Health is complying with all applicable laws and satisfying all of its legal obligations. When reasonably possible, Chrysalis Health will attempt to obtain your written consent prior to the release of such information, but does not guarantee that such attempt to obtain consent will be made.

Chrysalis Health may also disclose your service/treatment information and/or medical record information to the minimum extent necessary to a law enforcement official if you are a suspect, fugitive, material witness, crime victim, missing person, etc. Chrysalis Health may additionally disclose the service/treatment information and/or medical record information to the minimum extent necessary if you are an inmate or other person in lawful custody to a law enforcement official or correctional institution under certain circumstances or if it is necessary to assist law enforcement officials to capture an individual who has admitted to participation in a crime or has escaped from lawful custody.

(g) For Court Proceedings

Chrysalis Health may be required to use or disclose your service/treatment information and/or medical record information in response to a court or administrative order, subpoena, discovery request, or other lawful process, under certain circumstances. Under other limited circumstances, such as a court order, warrant, or grand jury subpoena, we may disclose your PHI to law enforcement officials. When reasonably possible, Chrysalis Health will attempt to obtain your written consent prior to the release of such information, but does not guarantee that such attempt to obtain consent will be made. Also, such information will only be released to the minimum extent necessary to satisfy the request.

(h) For Military and National Security

Chrysalis Health may disclose to military authorities your service/treatment information and/or medical record information if you are an Armed Forces personnel under certain circumstances or to authorized federal officials for lawful intelligence, counterintelligence, and other national security activities. When reasonably possible, Chrysalis Health will attempt to obtain your written consent prior to the release of such information, but does not guarantee that such attempt to obtain consent will be made prior to the disclosure. Also, such information will only be released to the minimum extent necessary to satisfy the request.

(i) For Research, Training or Quality Assurance

Chrysalis Health will not use or disclose any identifying information about you for: research, data, training or quality assurance unless we first (a) disclose to you in writing the purpose of such use, (b) limit the use of your information only to the extent necessary to fulfill such purpose, and (c) receive your written consent to such disclosure.

(j) For Media Purposes

Chrysalis Health will not disclose your protected health information to the media without your voluntary and written consent. In the event that you voluntarily or inadvertently disclose, on your own, such confidential information about yourself or another Chrysalis Health client, it is with the understanding that Chrysalis Health will not be held responsible for claims arising from your communications.

(k) For Other Purposes, With Your Consent

From time to time, situations may arise where we may need to disclose your confidential information under special circumstances. Such information will not be released unless we first (a) disclose to you in writing the purpose of such use, (b) limit the use of your information only to the extent necessary to fulfill such purpose, and (c) receive your written consent to such disclosure.

III. Your Rights

(a) Duration of Consent; Right to Revoke or Limit Consent to Disclose Information

At any time, if you give your written consent to Chrysalis Health to release your information for any purpose, your written consent to release your information for service/treatment will remain valid through the length of service/treatment, unless otherwise noted, or you revoke or limit your consent. You have the right to revoke or limit the consent in writing at any time (see Questions and Concerns section for details).

(b) Right to Request Amendments to Your Medical Record

You have the right to request that we amend your medical record by writing to the Medical Records department at Chrysalis Health. The writing must contain a detailed description of the amendments requested and the reasons for such request.

Under certain circumstances, we may deny your request to amend your medical record. If Chrysalis Health does so, we will provide you with a written reason for such denial within 14 days of receipt of the request for amendment. If you are unsatisfied with such response, you may use the procedures set out in the Questions and Concerns section of this Notice, to file an appeal.

(c) Right to Request Restrictions on the Use and Disclosure of your PHI

You have the right to request that we place certain additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement. However, if you are in need of emergency treatment and the restricted health information is needed to provide the emergency treatment, we may use or disclose that information to a health care provider in order to facilitate the provision of emergency treatment to you. Any agreement we may make to a request for additional restrictions must be in writing and signed by the person authorized to make such an agreement on our behalf. We will not be bound unless the agreement is so memorialized in writing.

(d) Right to Request Your PHI Log

You have the right to request a copy of your PHI log, which will show you all uses and disclosures of your PHI made by Chrysalis Health to other parties. Such request can be made in writing to the Privacy Officer at the address listed in the Questions and Grievance section of this notice.

(e) Right to Request Confidential Communications

You have the right to request that we communicate with you in confidence about your health information at an alternative address or location. To make such request, please make such request in writing to Chrysalis Health (see Questions and Grievances section).

IV. Others' Rights

During the course of service/treatment with Chrysalis Health, you may be privileged to the protected health information of other Chrysalis Health clients. When receiving such information, you agree to maintain the privacy of such other client's protected health information to the same extent as Chrysalis Health maintains your privacy.

V. Effective Date

This Privacy Notice takes effect on April 14, 2003 and will remain in effect until a revised notice is issued. A revised notice may be issued if (a) Chrysalis Health chooses to revise this Privacy Notice or its Policies or (b) federal or state regulations requires Chrysalis Health to make such revisions. Chrysalis Health reserves the right to make changes in its privacy practices. Before we make a significant change in our privacy practices which will effect your rights, we will change this notice and send the new one to you and, if you are under 18 years of age, to your legal guardian.

VI. Questions and Concerns

If at any time you want more information about Chrysalis Health's privacy practices, or, have questions or concerns about this Notice or Chrysalis Health's Privacy Practices, please contact our Privacy Officer who will answer any questions or concerns you may have. You may also file a grievance with our privacy officer at: Chrysalis Health, 3800 W. Broward Blvd., Suite 100, Fort Lauderdale, FL 33312, 954-587-1008, fax 954-587-0080.

Any grievance filed will be investigated by Chrysalis Health Management Team and the results of such investigation will be forwarded to you within 30 days of the receipt of your grievance. Furthermore, you have the right to submit any of your privacy grievance to the U.S. Department of Health and Human Services at: Secretary of Health and Human Services, 200 Independence Avenue, SW, Washington, D.C. 20201

Chrysalis Health supports your right to protect the privacy of your treatment information and medical record and will not retaliate in any way if you choose to file a grievance with us or with the U.S. Department of Health and Human Service.

Client Rights

As an individual and as a client of Chrysalis Health, you (the client) have the following rights, which we, the professional staff, recognize and respect. If at any time you feel that your rights have been violated, administration shall investigate, examine and seek to remedy the conditions and practices, which are found to have violated your rights, in accordance to our grievance procedures specified below. With that understanding, Chrysalis Health recognizes the following:

1. You have the right to seek treatment/services from any professional or agency of your choice.
2. You have the right to receive prompt assessment and treatment/services.
3. You have the right to individualized services specific to your needs.
4. You have the right to make all decisions regarding treatment/services, including the decision to participate or refuse treatment/services.
5. You have the right to participate in all service decisions, including the development and monitoring of your individualized treatment/service and discharge plans and requests for an in-house review of such plans. You have the responsibility to provide relevant information as a basis for receiving such services and participating in service decisions.
6. You have the right to be fully informed of the reason for admission, of an assessment of your problems, of the plan and purpose for treatment/services, of the foreseeable outcomes of treatment/services, of the common side effects of treatment/services, of alternative treatment/service modalities, of the approximate length of care and of your aftercare plan.
7. You have the right to receive services in a safe, skillful and humane manner without discrimination and with full respect for your dignity and personal integrity as an individual and human being, including the consistent and fair application of program rules.
8. You have the right to express and practice religious, spiritual and cultural beliefs.
9. You have the right to be treated/served under the least restrictive methods consistent with your condition.
10. You have the right to be free from any unnecessary treatment, services or restraint.
11. You have the right to be free from participation in research. Chrysalis Health assures you that it does not conduct or participate in any research whatsoever.
12. You have the right to refuse or terminate any specific treatment, services or medications at any time and for any reason, unless mandated by law or court order. If you refuse such treatment, services or medications, you have the right to be informed of the consequences.
13. You have the right to communicate freely and privately with persons outside of the facility, in person, by telephone or by mail, unless it is determined that such communication is likely to be harmful to yourself or others.
14. You have the right to keep your clothing and personal belongings in accordance with established safety and treatment/service policies.
15. You have the right to have your confidentiality and privacy protected according to federal, state and local law.
16. You have the right to review, copy and amend your medical record in accordance to federal, state and local law.
17. You have the right to be free from interference, coercion, discrimination, and/or reprisal.
18. You have the right to seek legal counsel.
19. You have a right to file a complaint/grievance with Chrysalis Health, without interference or retaliation, for any violations of your rights and to have your complaint investigated, reviewed and answered. Further, you have right to appeal any determination made in regard to your complaint. For more information about filing a complaint/grievance, please speak with your therapist or direct service provider.
20. You have the right to our assistance in understanding and exercising your rights assured under this section.
21. Under the No Surprises Act, you have the following rights:
    1. Right to a Good Faith Estimate: If the services are provided by out-of-network providers, you will receive a written good faith estimate of the charges at least 72 hours before the service is provided.
    2. Right to Informed Consent: You must be informed of the potential cost difference if you decide to receive non-emergency services from an out-of-network provider and consent to this arrangement in writing.
    3. No Balance Billing: You will not be charged more than the in-network cost-sharing amounts for situations where the No Surprises Act protections apply.

If you feel your rights have been violated or you have further questions about your rights, you may contact:

Chrysalis Health does not maintain or manage advanced directives for individuals receiving behavioral health services. Clients are encouraged to seek guidance from their legal or healthcare provider if they wish to create or update an advanced directive. If you already have a mental health Advance Directive, please provide Chrysalis Health with a copy.

If a client requests assistance with advanced directives, the agency may provide referrals to local healthcare providers, legal services, or other community resources that may assist in the process.

While advanced directives are not maintained by the agency, staff may document if a client has or does not have an Advanced Directive, and request a copy and details regarding their surrogate, but these will not be legally binding or treated as advanced directives. Any preference indicated by a client regarding care preferences can be documented in the clinical record, but the agency's responsibility does not extend beyond providing services in accordance with clinical needs.

Please be advised that if you believe you may be hospitalized for mental health care in the future and that your doctor may think you aren't able to make good decisions about your treatment, then completing a "Mental Health Advance Directive" will ensure that your treatment choices are known. It is important that you decide NOW what types of treatment you do or do not want and to appoint a friend or family member to make the mental health care decisions that you want carried out. You may always change your preferences or surrogate later. Please note that the person you choose to be your health care surrogate and alternate must be a competent adult whose civil rights have not been taken away.

Please be advised that Chrysalis Health is not intending to provide legal advice with regard to the advance directive, nor is it endorsing any of the forms referred to herein as being the appropriate form for you. Chrysalis Health is merely advising you of your rights and providing information as to where to look for an advance directive sample form. You should always consult with an attorney regarding your legal rights. The agency does not endorse, certify, guarantee or assume liability for any referrals to a client.

In the event that I have a legal guardian appointed and there is a 3rd Party acting on behalf of the legal guardian who has authority and consent to act and sign documents as I might or could do if personally present in relation to any service(s) rendered by Chrysalis Health, my consent will, among other things, grant the 3rd Party right to make treatment/service decisions on behalf of the client, to sign consent forms, to release or obtain any document on the client's behalf, to authorize treatment, to participate in and sign treatment plans and treatment plan reviews and to perform any other task that is necessary for the client's treatment with Chrysalis Health. I am aware that I can limit this consent to specific information or specific uses.

Further, I understand that I may revoke my consent in writing at any time to the extent that Chrysalis Health has not already taken action in reliance thereon. When and if revoking my consent, I agree to send the writing to the attention of "Privacy Officer." I understand that if I choose not to revoke or limit this consent, this consent will be valid throughout my entire length of treatment and/or services, as communication is necessary in order to provide me with effective treatment/services.

This health care behavioral health provider may engage you in the delivery of one or more of the requested services via telehealth. You have the option to decline telehealth services and instead seek face to face services.

Telehealth is the use of electronic communication technologies by health care providers to deliver services to individuals located at a different site than the provider. There are potential risks to this technology, including interruptions, technical difficulties, and much more rarely, unauthorized access. Certain conditions cannot be diagnosed or treated via telehealth, and the healthcare provider(s) will determine whether or not the condition being diagnosed and/or treated is appropriate for a telehealth encounter; if it is not, the provider will communicate this and explain alternative options.

In any telehealth visit, you will have a direct conversation with the health care provider and have the opportunity to ask any questions in regard to telehealth services. Questions shall be answered, and the risks, benefits and any practical alternatives discussed in a language you understand.

Others may also be present during the consultation other than the health care provider in order to set up or operate the video equipment, but all will maintain confidentiality of the information obtained. Because you are located in a setting outside of this provider's physical office, processes such as electronic appointment scheduling, electronic prescription orders/refills and patient education delivered electronically may occur.

All existing laws regarding access to medical information and copies of medical records apply to telehealth services. Please note that telecommunications are not recorded or stored. Reasonable and appropriate efforts have been made to eliminate confidentiality risks associated with telehealth technologies, and all existing confidentiality protections under federal and state law apply to information disclosed during telehealth sessions.

Chrysalis Health has given me information explaining how the video conferencing technology will be used and that the delivery of services may not be the same as a direct client/behavioral health provider visit due to the fact that I may not be in the same room as my health care provider.

I understand that my behavioral health provider or I may discontinue the telehealth session if it is felt that the videoconferencing connections are not adequate for the situation.

I further understand that I will be informed of any other person(s) presence in the consultation and have the right to request any of the following:

• Omit specific details of my medical history/physical examination that are personally sensitive to me
• Ask non-medical personnel to leave the telehealth room
• Terminate the consultation at any time

I have had the alternatives to telehealth explained to me, and in choosing to participate in telehealth services.

In an emergency situation, I understand that I have been instructed to call 911 or my attending physician and that the Chrysalis Health provider's responsibility will conclude upon the termination of the video conferencing connection.

I may withhold or withdraw consent to the telehealth services at any time, without affecting my right to future care or treatment.

As acknowledged in the consent form, I have received an orientation to Chrysalis Health's Treatment Program in a language myself or my representative understands and that my orientation included the following:

• Review of the Program Description. The program description was available to me at the time of admission and will be at any time upon request. A good faith estimate can be requested any time, per the No Surprises Act.
• I understand that the No Surprises Act protects me from certain unexpected billing situations but that I may still incur costs for out-of-network services.
• A review of the services available to me
• A copy of client rights pursuant to chapter 397, part III, F.S.
• A summary of admission and discharge policies
• Included access to information and participation in treatment planning
• A copy of the service fee schedule and program fees
• Client responsibilities and rules of conduct
• Continued Stay and Length of Stay Information
• Privacy Notice
• Grievance process and procedure
• General information about infection control policies and procedures
• HIV/AIDS educational material
• Limits of confidentiality
• Information on parental or legal guardian's access to information and participation in treatment
• Telephone numbers for Abuse Registry, Substance Abuse and Mental Health Program Office, & Florida Advocacy Council
• Information regarding advance directives — Adults only
• Overdose prevention information

The consent for services includes verification of program orientation.