Câu lạc bộ BJJ Hà Nội, 75 - Đặng Văn Ngữ
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Group Therapy Confidentiality Agreement Form

In order to protect the confidentiality of all class members, the customer also agrees: Ethos Behavioral Health Group, LLC and its affiliates (“Ethos”) offer, in appropriate circumstances, an option for clients in group therapy to participate in their group through telemedicine. This option is only available if all affected participants agree to the following authorization and approval. The client also agrees to protect the confidentiality of other members of the group who participate personally or by telemedicine: Unless otherwise stated, this group telemedicine authorization also allows us to see you by telemedicine for your individual sessions. [contact-form-7 id=”43997″ title=”Group Consent”] The undersigned customer (“customer”) gives the customer`s permission and authorization to participate in the telemedicine program of Ethos Behavioral Health Group, LLC and its affiliates (“Ethos”). While Ethos` telemedicine options, including Zoom, Facetime, and Cisco Web, are optimized for data protection, Ethos may not have formal counterparty agreements with these services (and no such agreement is available with Facetime), which may result in technical legal data protection issues. Customer agrees that these third-party services serve as a channel for the Customer`s protected health information and may have access to such information. The customer also understands that if the customer is not in a private location during access to telemedicine, others may see or listen to the customer`s protected health information. Therefore, the customer accepts and authorizes Ethos to transmit the customer`s protected health information to its telemedicine providers or to persons present with the customer, if the customer accesses Ethos` telehealth service, to the extent necessary for the use of Ethos` telehealth services for the purpose of the customer`s treatment. The customer also agrees to waive all applicable data protection provisions at the federal and regional level, including, but not limited to, HIPC protection and protection measures in accordance with 42 CFR Part 2, to the extent necessary to participate in Ethos` telemedicine options as described above.

This authorization is maintained until it is revoked by the customer. The customer may revoke this authorization at any time by contacting Ethos` compliance officer at tlankau@ethosbhg.com or 832-457-5046. The customer`s terms of service at Ethos are not affected if the customer manages not to sign this consent and authorization. If you decide to participate in a telemedicine group, you agree as follows: HIPPA Limited and 42 CFR Part 2 Telemedicine Approval and Authorization for Group Therapy.. . . .