The purpose of this consent form is to provide you with information about telehealth and to obtain your informed consent to the use of telehealth in the delivery of your healthcare services through online platforms owned and operated by BrightChoice Holdings LLC or its subsidiaries (collectively, “BrightChoice”). BrightChoice is a telehealth platform that makes available mental health care services to adults age 18 and older.

Telehealth involves the use of electronic communications between a patient and their provider (including secure video conferencing, phone calls, and messages) to provide healthcare services remotely. Telehealth may also include electronic transmission of medical records, personal health information, or other data shared between a patient and a provider, and output data collected by medical devices, sound, or video files. Telehealth enables you to obtain healthcare from your provider without needing to meet in person. Provider services available through the BrightChoice platform include mental health consultation, counseling, treatment, therapy, follow-up, and patient education.

Please read this form carefully. Your acceptance below indicates that you understand and agree that your healthcare provider will use telehealth in the delivery of mental health services to you using the online platforms owned and operated by BrightChoice.

Anticipated Benefits of Telehealth Services

• Increased access to mental health care services and a wide variety of providers.
• Convenient appointment times.
• The ability to meet with a provider in a location that is comfortable and without the necessity of an in-office appointment.
• Mental health care services may reduce stress and anxiety, decrease negative thoughts, improve relationships, and increase comfort in different settings.

Potential Risks

While telehealth may provide potential benefits, there are also potential risks associated with the use of telehealth and other technology, even though telehealth services are generally considered safe and effective. By agreeing to receive mental health care services through telehealth, you acknowledge the following:

• BrightChoice’s telehealth technology is intended to protect patient privacy. However, security protocols or safeguards could fail, causing a breach of privacy of medical or other information.
• In rare cases, the connection between you and your provider may be unstable or insufficient, which could lead to a failure in audio or video services.
• Technology may contain bugs or other errors that limit functionality, produce erroneous results, or otherwise affect records, data, or content.
• Technology failures may affect a healthcare provider’s ability to diagnose or treat a condition via telehealth.
• The inability to conduct tests or assess vital signs in person may prevent healthcare providers from providing a diagnosis or treatment, or from identifying a need for emergency medical care.
• Providers may not be able to provide treatment via telehealth for your particular condition, requiring you to seek alternative healthcare or emergency care services.
• Mental health care services may result in feeling worse as therapy progresses.
• A lack of access to all of your medical records may result in gaps or errors in treatment.
• Data and information stored and shared electronically (e.g., via email or text) may be more susceptible to unintended disclosure to third parties.

Location & Licensure Requirements

BrightChoice currently has therapists licensed to practice in the state of Indiana. In order to receive telehealth services, you must select a provider licensed in the state where you physically reside. At the beginning of each session, you will be asked to confirm that you are physically located in Indiana. If you plan to travel or be located outside of Indiana, you must inform your therapist beforehand. If you are physically located in a state where your therapist is not licensed, the telehealth session may not be legally permissible.

General Treatment Information (Beyond Telehealth)

Scope of Services: BrightChoice provides virtual mental health counseling (“talk therapy”) for adults age 18 and older, delivered exclusively via telehealth. Our independently licensed therapists offer both short-term and long-term therapy, using various counseling approaches based on their professional judgment and the client’s individual needs. BrightChoice does not provide medication management or diagnostic testing services at this time.

Nature of Therapy & Possible Benefits: Talk therapy is a process where you work collaboratively with a licensed provider to address concerns related to your emotional well-being and mental health. Therapy may help you:

• Develop coping strategies for stress, anxiety, depression, and other challenges.
• Gain insights into behavioral or relationship patterns.
• Improve your ability to communicate, set boundaries, and manage conflicts.
• Experience personal growth and self-awareness.

Many clients find therapy beneficial, but no specific results or outcomes can be guaranteed, and each individual’s progress will vary.

Potential Risks & Emotional Discomfort: It is important to recognize that mental health treatment involves exploring personal issues and can sometimes be challenging or uncomfortable. You may experience:

• Temporary increases in emotional distress or discomfort as you address difficult memories or issues.
• Shifts in relationships or personal perspectives that may feel unsettling at first.
• The possibility that certain treatment methods or interventions may not bring the desired improvement or may require adjustment over time.

These effects can be a normal part of the therapy process. Sometimes, therapy can feel worse before it feels better. If you find the emotional difficulty overwhelming, please inform your therapist so you can collaboratively adjust treatment goals or approaches.

Participation & Treatment Goals: Some therapists actively collaborate with clients to formulate treatment goals and measure progress throughout the therapeutic journey; others may guide sessions in a more provider-driven manner. You have the right to ask questions, voice concerns, and participate in decisions about your care. You may also refuse or withdraw from treatment at any time without affecting your future ability to seek services through BrightChoice.

Emergency/Crisis Protocol: BrightChoice is not a 24/7 crisis hotline or emergency care provider. If you ever feel you are in crisis or experiencing a life-threatening emergency, call 911, dial 988 for the Suicide & Crisis Lifeline, or go to the nearest hospital emergency department. For urgent concerns that are not life-threatening, you may contact your therapist to reach an on-call or backup provider if available. However, in any genuine emergency situation, you should always contact local emergency services immediately.

Legal & Geographic Coverage: All therapy services are provided in accordance with U.S. law and Indiana regulations. Our providers are licensed in Indiana, and we are currently only able to serve clients who reside in or are physically located in Indiana at the time of service.

Financial & Insurance Consents

Billing & Payment: BrightChoice charges the full session fee to your payment method on file upon completion of each appointment. Session fees may vary depending on the duration and nature of your appointment. If you fail to attend a scheduled session without sufficient notice, we may charge a no-show or late cancellation fee according to our cancellation policies.

Insurance Claims: If you have a PPO insurance plan that we accept, BrightChoice will submit claims on your behalf. However, you remain fully responsible for the total session cost, regardless of the amount that may or may not be reimbursed by your insurance company. Any reimbursement disputes or follow-up with your insurer are solely between you and your insurance carrier. By accepting these terms, you authorize BrightChoice to share limited information (e.g., diagnoses, procedure codes) with your insurer as required to process claims.

Financial Responsibility: You acknowledge that you are responsible for all fees or balances not covered by insurance, including copays, coinsurance, deductibles, and/or charges denied by your insurance plan. If you have questions about your coverage or financial obligations, please contact either BrightChoice or your insurance provider.

Acknowledgment: By continuing with BrightChoice’s services, you acknowledge that you have read and understand the above information regarding the nature of therapy, potential risks and benefits, participation in treatment, and financial and insurance obligations.

Privacy and Confidentiality

The electronic systems BrightChoice uses incorporate security protocols to protect privacy and security of information transmitted through and stored by the system. Your provider and BrightChoice will not share information that identifies you or that contains protected health information, unless you give consent or disclosure of the information is permitted or required by law (for example, reporting child abuse or if a patient is a danger to themselves or others). Data will be handled in accordance with the Notice of Privacy Practices.

Confidentiality Exceptions

BrightChoice and its providers follow all applicable state and federal laws regarding mandatory reporting and other confidentiality exceptions. These may include, but are not limited to, the following:

• Child Abuse, Elder Abuse, or Abuse of a Vulnerable Adult: If your provider suspects abuse or neglect, they may be legally required to report that information to the appropriate authorities.
• Threats of Harm to Self or Others: If you express a serious or imminent threat of harming yourself or others, your provider may be required to take protective actions such as arranging hospitalization, contacting family members or emergency contacts, or notifying law enforcement.
• Court Orders/Subpoenas: Your provider may be required to release confidential information if presented with a valid court order or subpoena.
• Immediate Danger Protocol: If your provider believes you are in immediate danger to yourself or others, they may break confidentiality to contact authorities or other resources to help ensure your safety.

Patient Rights and Responsibilities

By indicating consent, you understand that you have the right to receive clear information about your care, choose whether to participate in telehealth mental health care services or seek in-person care, and withdraw your consent to telehealth services at any time (without affecting your ability to seek future care through BrightChoice).

Mental health care services are the result of a collaborative relationship between you and your provider. By using BrightChoice services, you agree to:

• Provide accurate and complete information about your behavioral and mental health history, along with any other relevant conditions or treatments.
• Promptly pay for the services you receive, including authorizing BrightChoice to charge your payment method on file after each session or for any applicable no-show or late cancellation fee.
• Review and comply with BrightChoice policies regarding cancellations, no-show appointments, and rescheduling. You can find these policies at www.brightchoice.com.

Consent to Telehealth and Mental Health Care Services

By utilizing BrightChoice services for mental health care, you acknowledge and agree that:

• You have read and understood the information provided above, including the potential benefits and risks of telehealth services.
• You will provide BrightChoice and your healthcare provider with truthful, accurate, and complete information, including relevant information regarding other care you receive.
• Your provider may determine, in their sole discretion, that telehealth is appropriate for your condition. Continuing to use BrightChoice services indicates that you agree with the provider’s assessment.
• Your provider may determine, in their sole discretion, that your condition is not suitable for telehealth services, requiring you to seek treatment from a specialist or mental health provider outside of the telehealth service.
• No guarantees have been made as to the outcome or results of your use of the services.
• Services will be provided by a licensed provider, and you have access to information about their credentials.
• You voluntarily consent to receive mental health care services via telehealth.