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This document contains important information about our decision (yours and mine) to resume in-person services in light of the COVID-19 public health crisis. Please read this carefully and let me know if you have any questions. When you sign this document, it will be an official agreement between us.

Decision to Meet Face-to-Face

We have agreed to meet in person for some or all future sessions. If there is a resurgence of the pandemic or, if other health concerns arise, I may require that we meet via Telehealth. If you have concerns about meeting through Telehealth, we will talk about it and address any issues you have. You understand that, if I believe it is necessary, I may determine that we return to Telehealth for everyone’s well-being.

If you decide at any time that you would feel safer staying with, or returning to, Telehealth services, I will respect that decision, as long as it is feasible and clinically appropriate. Reimbursement for Telehealth services, however, is also determined by the insurance companies and applicable law, so that is an issue we may also need to discuss if it arises.

Risks of Opting for In-Person Services

You understand that, by coming into the office, you are assuming the risk of possible exposure to the coronavirus (or other public health risk). This risk may increase if you travel by public transportation, cab, or a ride sharing service.

Your Responsibility to Minimize Your Exposure

To obtain services in person, you agree to take certain precautions which will help keep everyone (you, me, our families, and other patients) safer from exposure, sickness and possible death. If you do not adhere to these safeguards, it may result in our starting/ returning to a Telehealth arrangement. Please check the box next to each statement below to indicate that you understand and agree to these actions:

I may change the above precautions if additional local, state or federal orders or guidelines are published. If that occurs, we will discuss any necessary changes.

My Commitment to Minimize Exposure

My practice has taken steps recommended by the CDC to reduce the risk of spreading coronavirus within the office and have posted these efforts on our website and in the office. Please let me know if you have any questions about these efforts.

If One of Us is Sick

You understand that I am committed to keeping you, me, and all of our families safe from the spread of this virus. If you show up for an appointment and I believe that you have a fever, other relevant symptoms, or have been exposed, I will require you to leave the office immediately. We can follow-up with services by Telehealth as appropriate.

If I test positive for the coronavirus, I will notify you so that you can take appropriate precautions.

Your Confidentiality in Case of Infection

If you or I have tested positive for the coronavirus, I may be required to notify local health authorities that you have been in the office. If I have to report this, I will only provide the minimum information necessary for their data collection and will not go into any details about the reason(s) for our visits. By signing this form, you are agreeing that I may do so without an additional signed release.

Informed Consent

This agreement supplements the original Informed Consent that was signed at the start of our work together.

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