MINDYRA CONSENT FORM
This User Consent Form covers all users of the Mindyra app or web based services, whether an adult individual, a member of an Organization (adult employee, student or member), an adult dependent of a user, or a minor dependent overseen by an adult user (each a “User”).
USER CONSENT FORM
Please review the following statements. Use of this App or the Mindyra Health Corporation (“Mindyra”) website means you have accepted the terms of this User Consent Form.
- I understand that I have chosen to use this App or website as an individual or as available to me as part of an employee/ collegiate/ membership organization (each an “Organization”), which includes various online education, screening and reporting tools (“Mindyra Services”) that are provided by Mindyra, and I desire to use the App and/or website.
- I understand that Mindyra DOES NOT directly offer therapy or medical services, does not sell therapy or medical services and does not diagnose individuals. Confirmation of responsibility for payment for any third party services rendered must be mutually agreed by the User and any third party provider before any service is delivered.
- I understand that Mindyra is not responsible for the content of third party resources listed on its website or in the App. This information is provided as an educational service and Users are ultimately responsible for identifying and selecting the form of intervention that meets their needs.
- I understand that Mindyra shall have the right to de-identify my data in accordance with federal privacy rules and aggregate and use such data for purposes of enhancing Mindyra Services to improve quality of care, for technical support and/or for other purposes without compensation to me or any other person. I further understand that if I am using this program as part of an Organization benefit, any information shared with my Organization will be aggregated and de-identified in accordance with federal privacy rules and will NOT be identifiable by my Organization. The use of Mindyra Services is TOTALLY CONFIDENTIAL.
- If I desire teletherapy, mediated peer support or other third party services, and if they are available to me through the App, I authorize Mindyra to provide my name and contact information to the third party in order to connect me with these services, and upon establishment of an appointment, access to other demographic and healthcare information about me acquired by the Mindyra system, including Mindyra test results, to the teletherapy professional or telemoderator or any other teleprofessional (each a “Provider”) for the purposes of my receiving services from that Provider.
- I understand that once Mindyra discloses the above-mentioned information, it cannot guarantee that the information will not be re-disclosed by the recipient, though certain information remains protected by federal privacy laws or regulations. I understand that this authorization shall expire when I cease receiving services through the Provider, unless I earlier revoke this authorization, as described below.
- I also authorize the Provider to share my name, demographic, treatment, and other healthcare information with Mindyra to support my care.
- I understand that I have a legal right to revoke this authorization at any time by contacting Mindyra at info@mindyra.com. I understand that the revocation will not apply to information that has already been released in response to this User Consent Form. I understand that Mindyra has no control over the care provided by Providers and is not responsible for any of the services provided by Providers.
- I understand my signing of this User Consent Form is voluntary. I can contact Mindyra at info@mindyra.com if I have any questions.
- By using this App or the Mindyra website, I acknowledge that I have read and understand this User Consent Form. If I am using the App on behalf of my minor children, I am accepting all of the above on their behalf.