If patient is a minor, please complete the following. If not applicable, leave these blank.

Hope419 Virtual visits are a form of telemedicine that allows patients to access psychiatric care using audio-video interface such as videoconferencing. Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

Expected Benefits: Improved access to psychiatric care by enabling a patient to remain in his/her home or office. More efficient psychiatric evaluation and management. Obtaining expertise of a distant specialist.

Possible Risks: As with any medical procedure, there are potential risks associated with the use of virtual visits. These risks include, but may not be limited to: In rare cases, information transmitted may not be sufficient to allow for appropriate medical decision making by the physician and consultant(s); delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment; security protocols could fail, causing a breach of privacy of personal medical information; and lack of access to complete medical records may result in adverse drug interactions, allergic reactions, or other judgmental errors.

Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and ensure its integrity against intentional or unintentional corruption. Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with the Telehealth consultation.

During the Virtual consultation: Details of your medical history, examinations and tests will be discussed using interactive video and/or audio. A virtual examination may take place. Other medical professionals such as Medical Assistants and/or Scribes may be present during the visit to assist the provider, and photographs may be taken of you during the service. In an emergency, it is the responsibility of the Virtual provider to direct the patient to emergency medical services, such as an emergency room. The Virtual provider's responsibility will end upon the termination of the connection.

1. Technological Limitations: Virtual treatment requires a stable internet connection and functioning audio/visual equipment. Poor connectivity may lead to incomplete assessments or interruptions in care. Technical failures may interfere with diagnosis, treatment, and continuity of care.

2. Reduced Observational Data: Telehealth limits the clinician's ability to observe non-verbal cues, subtle behaviors, and environmental factors, which may affect diagnostic accuracy. Physical examinations are not possible, and certain psychiatric or neurological symptoms may be more difficult to assess remotely.

3. Emergency Limitations: Telehealth is not appropriate for managing acute psychiatric crises or medical emergencies. Patients should contact 911 or go to the nearest emergency room if they are in crisis or if a life-threatening situation arises during or outside the session.

4. Confidentiality and Privacy Risks: While efforts are made to ensure secure communication, there is a risk of unauthorized access or data breaches. Patients should ensure they are in a private space during sessions and use personal, secure devices to help maintain confidentiality.

5. Licensure and Jurisdiction Constraints: Providers may only offer virtual services in states or regions where they are licensed. This WILL limit care if the patient is not physically in the state of OHIO; all other locations are out of the jurisdiction.

6. Environmental Control: The provider cannot control the patient's environment, which may influence treatment effectiveness or patient disclosure.

7. Treatment Modality Appropriateness: Telehealth may not be suitable for all clinical presentations. Certain conditions may require in-person care. The clinician may recommend transitioning to in-person treatment if telehealth is no longer appropriate.

8. Informed Consent and Documentation: Patients must understand these limitations and agree to virtual treatment based on full disclosure of risks, benefits, and alternatives. Documentation of informed consent, including acknowledgment of telehealth's limitations, is required prior to initiation of services.

The laws that protect privacy and the confidentiality of medical information also apply to virtual visits, and no information obtained in the use of virtual visits which identifies you will be disclosed to researchers or other entities without your consent. You have the right to withhold or withdraw your consent to the use of virtual visits in the course of your care at any time, without affecting your right to future care or treatment. You have the right to inspect all information obtained in the course of a virtual visit, and may receive copies of this information for a reasonable fee. There are a variety of alternative methods of mental health care available to you, and you may choose one or more of these at any time. It is your duty to inform Hope419 of your desire to change to in-office visits. You may expect anticipated benefits from the use of virtual visits in your care, but no results can be guaranteed or assured.

Hope419 participates with many, but not all insurance plans. It is your responsibility to contact your insurance company to verify that we participate with your plan and the physician you will be seeing is in network with them. It is also your responsibility to provide accurate insurance information prior to the service. If you do not have your up-to-date insurance information, we will reschedule your appointment or classify your appointment as self-pay. Telehealth/Virtual services may not be covered by all insurance plans. If your insurance does not cover the virtual visit, you will be considered self-pay and our published self-pay fee will apply. Non-covered virtual visits will be the patient's responsibility.

$275 First Medication Management visit
$170 Follow-up Medication Management visits
$150 First Therapy visit
$100 Follow-up Therapy visits

ACCORDING TO OHIO LAW, IN ORDER TO BE ABLE TO PARTICIPATE IN A VIRTUAL APPOINTMENT WITH YOUR HOPE419 PROVIDER YOU MUST BE PHYSICALLY LOCATED IN THE STATE OF OHIO DURING THE TIME OF YOUR VIRTUAL VISIT.

If you are in crisis or in need of emergent help, please contact one of the following:

988 Suicide & Crisis Lifeline: Dial 988
National Suicide Prevention Lifeline: 1-800-273-8255
Richland County Sheriff: 419-524-2412
Ontario Police: 419-529-2115
Ontario Fire: 419-529-4416
Ashland County Sheriff: 419-289-3911
Ashland Police: 419-289-1911
Ashland Fire: 419-289-6511
Huron County Sheriff: 419-668-6912
Norwalk Police: 419-663-6780
Norwalk Fire: 419-663-6790
Wayne County Sheriff: 330-287-5750
Wooster Police: 330-287-5702
Wooster Fire: 330-642-2100