Associated Therapists, Inc.
INFORMED CONSENT FOR IN-PERSON SERVICES DURING COVID-19 PUBLIC HEALTH CRISIS

This document contains important information about your decision to resume or begin in-person services in light of the COVID-19 public health crisis. Please read this carefully. Let the office staff know if you have any questions. When you sign this document, it will be an official agreement.

The decision to Meet Face-to-Face
You 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, however, your provider may require that you meet via telehealth (or other arrangements). If you have concerns about meeting through telehealth, your provider will talk about it with you first and try to address any issues. You understand that, if your provider believes it is necessary, he/she may determine that the return to telehealth (or other arrangements) is for everyone’s well-being.

If you decide at any time that you would feel safer staying with, or returning to, telehealth (or other arrangements) services, your provider 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 that may also need to be discussed.

Risks of Opting for In-Person Services
You understand that by coming to the office, you are assuming the risk of exposure to the coronavirus (or other public health risks). This risk may increase if you travel by public transportation, cab, or ridesharing service.

Your Responsibility to Minimize Your Exposure
To obtain services in person, you agree to take certain precautions that will help keep everyone safer from exposure, sickness, and possible death. If you do not adhere to these safeguards, it may result in starting/returning to another arrangement. By signing this document you certify that you agree to the following actions:

• You agree only to keep your in-person appointment if you are symptom-free.

• You agree to take your temperature before coming to each appointment. If it is elevated (100 Fahrenheit or more), or if you have other symptoms of the coronavirus, you agree to cancel the appointment. If you cancel for this reason, there will not be a cancellation fee.

• You agree to wait in your car or outside [or in a safer waiting area] until no earlier than 5 minutes before your appointment time.

• You agree to wash your hands or use an alcohol-based hand sanitizer when you enter the building.

• You agree to adhere to the safe distancing precautions in the waiting room and testing/therapy room. For example, you won’t move chairs or sit where we have signs asking you not to sit.

• You agree to wear a mask in all areas of the office.

• You agree to keep a distance of 6 feet and there will be no physical contact (e.g. no shaking hands) with your provider or office staff.

• You agree to try not to touch your face or eyes with your hands. If you do, you will try to immediately wash or sanitize your hands.

• If you are bringing your child, you agree to make sure that your child follows all of these sanitation and distancing protocols.

• You agree to take steps between appointments to minimize your exposure to COVID.

• If you have a job that exposes you to other people who are infected, you agree to immediately let your provider and office staff know.

• If your commute or other responsibilities or activities put you in close contact with others (beyond your family), you agree to let your provider and staff know.

• If a resident of your home tests positive for the infection, you agree to immediately let your provider and office staff know and you will [begin] resume treatment via telehealth (or other arrangements).

Our office may change the above precautions if additional local, state or federal orders or guidelines are published. If that happens, your provider and/or our office staff will talk to you about any necessary changes.

Our Commitment to Minimize Exposure
Associated Therapists has taken steps to reduce the risk of spreading the coronavirus within the office and we have posted our efforts on our website and in the office. Please let us know if you have any questions about these efforts.

If You Are Sick
You understand that we are committed to keeping you, your provider, office staff, and all of our families safe from the spread of this virus. If you show up for an appointment and your provider or office staff believe that you have a fever or other symptoms, or believe you have been exposed, we will have to require you to leave the office immediately. We can follow up with services by telehealth, or other arrangements as appropriate.

If your provider test positive for the coronavirus, Our office will notify you so that you can take appropriate precautions.

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

Informed Consent
This agreement supplements the general informed consent/business agreement that you agreed to at the start of your services with our office.

Your signature below shows that you agree to these terms and conditions.