Notice of Consent

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THE INFORMATION. PLEASE REVIEW CAREFULLY:

I am required by the Health Insurance Portability & Accountability Act of 1996 (HIPAA) to provide confidentiality for all medical/mental health records and other individually identifiable health information in my possession. This Notice is to inform you of the uses and disclosures of confidential information that may be made by The Z Production Group, Inc, and of your individual rights and ESADoggy.com’s legal duties with respect to confidential information.

Ways in which I may use and disclose your protected Health information:

I may use and disclose at my discretion your medical records for each of the following purposes only: treatment, payment and health care operations.

Treatment means providing, coordinating or managing mental health care and related services.

Payment means activities such as obtaining payment for the mental health care services I provide for you from your insurance or another third party payer.

Health care operations include the business aspects of running a practice.

I may contact you to provide appointment reminders or other services that may be of interest to you. I will disclose your protected health information to any person you identify that is involved in payment for your care.

I will use and disclose your protected health information when required by federal, state or local law. There are certain situations in which as a therapist I am required by ethical standards to reveal information obtained during therapy to persons or agencies ­ even if you do not give permission. These situations are as follows: (a) If you threaten grave bodily harm or death to yourself or another person, I am required by ethical standards to inform the intended victim and/or appropriate law enforcement agencies; (b) if you report to me your knowledge of physical or sexual abuse of a minor child or of an elder (over 65) or any sexual conduct/contact with a minor, I am required by law to inform the appropriate child welfare or social agency which may then investigate the matter; (c) if I am required by a court of law (court order) to turn over records to the court or if I am ordered to testify regarding those records.

Any other uses and disclosures will be made only with your written authorization. You will be provided with an authorization form upon request. A separate form will be needed for each request for release of information. The authorization for release of records is valid until it expires or is revoked. You may revoke authorization in writing a I am required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.

Using Telemedicine

Telemedicine is the delivery of psychological services using electronic systems where the provider and the patient may not be in the same physical location. These online systems incorporate security protocols designed to protect the confidentiality of patient information and to safeguard the data against intentional or unintentional corruption. These electronic systems may not comply with HIPAA, (Health Insurance Portability and Accountability Act of 1996), legislation that provides data privacy and security provisions for safeguarding medical information. I understand this information and give my informed consent to the use of telemedicine during my treatment and expressly agree to hold ESADoggy.com harmless for any unforeseen or negligent data breach regarding my personal or medical information which may occur as a result of the use of this technology.

In considering telemedicine as an option, I know other options available to me, including face-to-face counseling. I understand that there are both advantages and disadvantages to telemedicine.

Some of the advantages include:

  1. The convenience of connecting with a therapist from my office or home.
  2. Less time in the waiting room.
  3. Cost-efficiency, including reduced travel expenses.
  4. Privacy assurance. Telemedicine complies with HIPAA laws.

Some of the disadvantages include:

  1. Telemedicine is not a good fit for every condition or situation
  2. There is a risk that intercepted electronic information, despite efforts to make it secure
  3. I would not always have immediate access to my clinician In case of emergency.

I acknowledge the list below contains trained mental health professional who can provide emergency services to me if needed. I have diligently and carefully considered how I may receive counseling services and hereby consent to receive counseling services via telemedicine from ESADoggy and its independent clinicians. If I have further questions about telemedicine or my rights as a client, I will ask my questions to my assigned clinician as soon as possible. I recognize that I may withdraw my consent at any time by notifying ESADoggy in writing of my decision to discontinue telemedicine services.

Not a Diagnostic Instrument

This form is not a diagnostic instrument and is to be used solely within the context of your medical treatment with a healthcare provider.

The maker and provider of this form disclaim any liability, loss, or risk incurred as a consequence, directly or indirectly, from the use and application of any of this material. The actions of your emotional support animal are the full responsibility of its owner.

By completing this form, you are providing your consent to ESADoggy.com to store and review your questionnaire to connectyou with a licensed health professional so they can review your questionnaire. We are not guaranteeing that a mental health professional will issue a recommendation for an ESA.

About Your Emotional Support Animal

ESADoggy.com makes no designation as to the specific animal an individual designates as their Emotional Support Animal, no representation of that animal’s fitness to serve, and assumes no liability for any actions of the Emotional Support Animal and handler UNDER ANY CIRCUMSTANCE. ESADoggy.com also accepts no responsibility for the denial of privileges associated with any Emotional Service Animal. Submission of payment and your evaluation constitutes acceptance of these terms.

You are really important to us, and we want to provide you with the best support we can.

We know from experience that when someone is experiencing this level of distress, an Emotional Support Animal may not be the most appropriate solution.

We advise you to please use the following resources now:

Emergency: 911
National Domestic Violence Hotline:
1- 800-799-7233
National Suicide Prevention Lifeline: 1-800-273-TALK (8255)
National Hopeline Network: 1-800-SUICIDE (800-784-2433)
Lifeline Crisis Chat (Online live messaging): http://www.crisischat.org/
Crisis Text Line: Text “START” TO 741-741
Self-Harm Hotline: 1-800-DONT CUT (1-800-366-8288)
Family Violence Helpline: 1-800-996-6228
Planned Parenthood Hotline: 1-800-230-PLAN (7526)
American Association of Poison Control Centers: 1-800-222-1222
National Council on Alcoholism & Drug Dependency Hope Line: 1-800-622-2255
National Crisis Line – Anorexia and Bulimia: 1-800-233-4357
GLBT Hotline: 1-888-843-4564
TREVOR Crisis Hotline: 1-866-488-7386
AIDS Crisis Line: 1-800-221-7044
Veterans Crisis Line: https://www.veteranscrisisline.net
Suicide Prevention Wiki: http://suicideprevention.wikia…

Due to the personal and sensitive nature of assessment, counseling, and testing, questions regarding confidentiality are completely understandable. Should you have additional questions about the confidentiality of our services, please drop us a note.

All therapeutic services at ESADoggy.com are strictly confidential. This means that nothing you share with us is revealed to anyone without your permission. We are not allowed to even disclose your name or identifying information to anyone including your family, other physicians, or places of business. Our psychological services are bound by the legal requirements of the National Privacy Principles from the Privacy Amendment (Private Sector) Act 2000.

In order to provide you with the highest quality of care, we may consult with various clinicians in the ESADoggy.com network. Other than these internal consultations, it is completely your decision whether to tell anyone that you are using our services.

We are unable to guarantee a confidential phone line, since wireless technology may be used in this process.

INFORMED CONSENT

I understand that the information obtained in this evaluation is confidential and will not be released to any person or organization without my written permission. (This release is available in our office or may be completed with any individual whom you wish to give such access, and then provided to us.) The only exceptions to this policy are rare situations in which you are required by law to release information with or without my permission. These are: 1) if there is evidence of physical and/or sexual abuse of children or abuse to the elderly; 2) if you judge that I am in danger of harming myself or another individual; and 3) if my records are subpoenaed by the court. In the rare event of any of these situations, you would attempt to discuss your intentions with me before an action is taken, and you would limit disclosure of confidential information to the minimum necessary to insure safety.

I understand that I have the right to discontinue the evaluation process at any time. However, I understand that FloridaESA may be unable to provide feedback of the test results if testing is terminated.

By my signature below, I acknowledge that I consent to a psychological evaluation by FloridaESA, that I have been informed of the policies regarding evaluations. I fully understand my rights and obligations as a client and I freely agree to this assessment.

Are there limits to confidentiality?

Yes. There are situations in which we are required by law and/or professional ethics to release information.

These include:

  • Our assessment that you may be a danger to yourself or others.
  • Our assessment that a child or elder is being abused, neglected, or exploited.
  • If we are required to present records or information as a part of a legal proceeding and are subpoenaed by the court.

Although these are very rare occurrences, should any of these situations arise, our staff will make every effort to discuss with you what steps will be taken.

What about airline inquiries?

Some airlines do, in fact, check to make sure that the mental health professional who signs your treatment recommendation letter for an emotional support animal is a licensed clinician, although they typically do this via online verification by a state board of certification website (there’s one for each state).

By federal law, a mental health professional or related agency is unable to release any information about a client without his or her express written permission. Airlines and other businesses may call or email us (our contact info and office telephone number is listed on the “contact us” page of this website) to verify licensure information, but it is unlawful for us to confirm even the name of a client.

Authorization and Consent To Send Unencrypted Patient Information by Email and Other Electronic Means

Until I tell you in writing to stop, I authorize ESADoggy.com to transmit patient information relating to my treatment without encryption or special security precautions, to me or someone I designate.

The patient information to be emailed will only include Emotional Support Animal letters.

I understand that:

  • I do not have to sign this form.
  • My treatment and payment will not be affected by my decision about signing this form.
  • If I don’t sign this form, ESADoggy.com may use other ways to send my information, such as U.S. Mail, or may ask me to send my information to third parties myself.
  • There is some risk that emails and other electronic messages may be improperly acquired by hackers or received by unintended recipients. If that happens, the information may be redisclosed and no longer protected by privacy law.
  • ESADoggy.com does not email such sensitive personal information as Social Security number, credit card number, or personal health information unless the patient insists.
  • I can tell you in writing to stop emailing my patient information at any time, but if I do so, this will not affect emails that ESADoggy.com already sent before receiving my written instructions to stop.

Release of liability

I confirm that the information provided by me regarding my diagnosis and medical records is true and correct. I request a letter for emotional support animal to help my mental health condition and symptoms stated and described above.

I hereby declare that I have completely and truthfully disclosed all information regarding my medical condition and attest that I am not a member, employee or agent of any media or law enforcement agency.

I am aware that my emotional support animal letter may be revoked at any time if I have perjured or misrepresented myself or my condition.

I attest that the information on this form is true and correct and that any medical history presented or discussed is also factual and complete to the best of my knowledge.

I DO NOT plan or intend to use my Emotional Support Animal certification for the purpose of illegally.

I attest that this particular animal has not shown any signs of aggression.

I affirm that I have a serious mental health condition that adversely affects my quality of life.

I voluntarily consent to receive health care services.

I have been assured that medical records relating to my care will be kept private and confidential and that no information will be released or printed, which would disclose my personal identity, unless required by law.

I, the undersigned, hereby request an evaluation for the purpose of determining the appropriateness of Emotional Support Animal.

I am legally 18 years old and above to get the Emotional Support Animal Letter.

I accept ownership of packages turned over to postal delivery service agents transfers to the buyer.

I accept that ESADoggy.com is not responsible for lost, held, or damaged packages.

I accept that ESADoggy.com is not responsible for mis-delivery errors via carrier, or incorrect shipping info. Shipping is a service you purchase from the carrier along with your order from us, so any shipping issues must be handled by the carrier.

I accept that ESADoggy.com is not responsible for late/missed deliveries due to the any Act of God or labor strike.

Practitioners engaged by ESADOGGY.COM are addressing specific aspects of my medical care, and unless otherwise stated are in no way establishing themselves as primary care provider.

Furthermore, the undersigned, my heirs, assigns, or anyone acting on my behalf, hold the physician, the principals, agents and employees, free and harmless of any liability resulting from the use of the Emotional Support Letter.

I accept all the risks above and will not hold ESADOGGY.COM, staff, and practitioners responsible for any legal ramifications.

I attest that I will consult with a psychologist or a psychiatrist if I am using for bipolar or any other psychiatrist condition.

I attest that the information on this form is true and correct and that any and all representatives that I made related to my medical history also true, factual and complete.

Based on my belief and general information that I have obtained from different sources, which includes researching scientific literature about the established benefits of Emotional Support Animal to help my medical condition. I request a practitioner to evaluate me and to issue me an Emotional Support Animal certificate.

In consideration of the benefits conferred upon you, actual or perceived, the sufficiency of which you hereby acknowledge, you agree that ESADoggy, and all principals and agents thereof, including but not limited to management, staff, and outside service providers, are not liable for any direct, indirect, incidental, special, consequential, punitive or treble damages, including without limitation, any and all damages resulting from temporary or permanent loss of housing, loss of use, loss of business, loss of revenue, loss of profits, or loss of data, arising out of, or in connection in any way with this Agreement, ESADoggy’s performance of services, or of any other obligations directly or indirectly related to this Agreement. You agree that said limitations are in full force and effect even if ESADoggy has been advised or noticed, at any time, of the possibility or potential of such damages. The foregoing limitation of liability shall apply regardless of the cause of action under which damages may be sought.

AGREEMENT TO ARBITRATE: It is understood that any dispute as to services rendered under this contract were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered, will be determined by the submission to arbitration as provided by Florida Law, and not by a lawsuit or resort to court process except as Florida law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any dispute decided in a court of law before a jury, and instead, are accepting the use of arbitration.

I DECLARE UNDER PENALTY OF PERJURY THAT THE INFORMATION ON THIS FORM IS TRUE AND CORRECT.