This Notice Describes Our:
PUBLIC HEALTH EMERGENCIES (PANDEMICS AND EPIDEMICS, e.g., COVID-19, etc.) PRACTICE POLICIES
PLEASE REVIEW IT CAREFULLY.
Version 24.1
Updated 3/12/24
THIS ACKNOWLEDGEMENT INCLUDES POLICIES ON PUBLIC HEALTH INFORMED CONSENT,
WAIVER, RELEASE AND ASSUMPTION OF THE RISK FOR IN-PERSON SERVICES DURING PUBLIC HEALTH CRISIS.
Introduction
This document contains important information about our decision (mutually between client(s) and Inclusion Therapies, as a healthcare provider) to resume modified in-person services during the COVID-19 public health crisis (and any other similar public health events). Please read this carefully and let our office know if you have any questions. When you sign this document, it will be an official and binding agreement.
Inclusion Therapies LLC (hereinafter "IC"), is a commercial entity in the City of Austin and our revised health and safety plan is in Compliance with the City of Austin Order ORDER NO. 20200622-015 (as of June 23rd, 2020) and all subsequent City of Austin Orders including, but not limited to, ORDER NO. 20220113-036 (effective January 13th, 2022).
Our Public Health Responsibility
To keep our staff and the persons we serve as safe and healthy as possible:
- All of our staff are fully vaccinated (as of March 1, 2021 to present).
- We will continue to follow CDC guidelines regarding handwashing and social distancing and Interim Infection Prevention and Control Recommendations.
- We will discontinue health surveys for each session for clients receiving in-person services after June 10th, 2021 and will require clients to let us know (as soon as possible) if they have been exposed to COVID-19.
- If clients present for in-person services with symptoms (coughing, breathing difficulty, fever, vomiting, etc.), we reserve the right to suspend in-person services pending client confirmation that they have not been exposed to COVID-19 or any variant thereof (we have telehealth online sessions available at all times).
- We will continue to provide PPE for staff and clients at each indoor location (including masks, hand sanitizer, and sanitizing wipes).
- Our staff will have PPE on their person and/or in their vehicle for any offsite/ outdoor locations.
A. Decision to Meet Face-to-Face
We, client and Inclusion Therapies LLC, 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; IC may require that we meet via only telehealth. If client decides at any time to stay with, or return to, telehealth services, that option is available as long as client funding sources reimburse IC for that modality. If a client, or anyone in your household, has been diagnosed with COVID-19 (or any variant thereof) or around anyone with COVID-19 or has symptoms (cough, fever, etc.), you must let us know as soon as possible. No therapist or staff member will work if they have symptoms or have contact with anyone with COVID-19 (or suspected to have it).
B. Risks of Opting for In-Person Services
Client understands that by coming to the IC center location and/or having provider(s) deliver home or community-based services, client is assuming the risk of exposure to the coronavirus (or other public health risks). This risk may increase if client travels by public transportation, cab, or ridesharing service.
1. Waiver, Release and DischargeClient agrees to fully and forever waive, release and discharge IC from any and all claims, actions, causes of action, demands, judgments, damages (including compensatory, general, special, consequential, exemplary and punitive), liability or obligations of any nature or kind, whether known at the time of delivery of healthcare service or which may arise or become known later, which accrue on account of, or in any way arise out of or in connection with:
(i) client activities within the scope of healthcare service delivery by IC;(ii) the activities within the scope of IC healthcare service delivery by other third parties(iii) regardless of whether such claims are founded in whole or in part upon alleged negligence, or the actual negligence of IC;(iv) client use of any and all of the activity facilities; and(v) client use of any and all equipment within the healthcare session, whether owned by client, IC or a third party;
2. Indemnification & Assumption of the RiskClient agrees to indemnify and hold IC harmless from and against any and all losses, liabilities, claims, obligations, costs, damages, and/or expenses whatsoever, including, but not limited to, any and all attorneys' fees, costs, damages and/or judgments directly or indirectly arising out of, or relating to client acts or omissions while participating in any activities related to the delivery of healthcare services by IC. Client agrees to accept and assume all of the risks which accompany IC’s healthcare service delivery activities and represent that client's participation in the activities is purely voluntary and client elects to participate in the activities notwithstanding the risks; and client certifies that client has adequate insurance to cover any injury or damage client may cause or suffer while participating in the activities within the scope of healthcare service delivery by IC, or if not, client agrees to bear the costs of such injury or damage to client and others.
C. Client’s Responsibility to Minimize Exposure
To obtain services in person, client agrees to take certain precautions which are anticipated to help keep the public (including, but not limited to, client themselves, IC providers and staff, families, friends of aforementioned individuals and other clients of IC, etc.) safer from exposure, sickness and possible death. If client does not adhere to these safeguards, it will result in starting / returning to a telehealth arrangement. By your signature on this Informed Consent document, client indicates that client understands and agrees to these actions:
o Client will only keep in-person appointment(s) if client (and anyone in their household) is symptom free and has not received positive test results for COVID-19.o Client will take client’s temperature before coming to each appointment. If it is elevated (100 Fahrenheit or more), and/or if client has other symptoms of the coronavirus, client agrees to cancel the appointment or proceed using telehealth.o As per City of Austin ORDER NO. 20200622-015: “ORDER NO. 20200622-015”: “Before visiting a healthcare provider or seeking emergency medical care, a person must notify the healthcare provider in advance (or the 9- 1-1 call taker and first responders in the event of an emergency) if they have tested positive for COVID19 or show symptoms consistent with COVID-19 such as cough, fever, sore throat, chills, muscle aches, loss of smell, loss of taste, shortness of breath, vomiting, and/or diarrhea, or if they have been exposed to another individual who tested positive or displayed symptoms consistent with COVID-19.”o The above is subject to change if additional local, state or federal orders or guidelines are published. If IC staff or providers test positive for the coronavirus, we will notify client.
D. Your Confidentiality in the Case of Infection
If client has tested positive for the coronavirus, IC may be required to notify local health authorities that client has been a recipient of healthcare services. By signing this form, client is agreeing that IC may do so without an additional signed release.
E. Informed Consent Supplement
This agreement supplements any and all general informed consent/business privacy agreements related documents that client has previously agreed to.
F. Performance
This Agreement is performable in Austin, Travis County, Texas. Jurisdiction and venue of any dispute arising hereunder are also performable in the city of Austin, Travis County, Texas. Client agrees that if any portion of this agreement is found to be void or unenforceable, the remaining portions shall remain in full force and effect.
G. Arbitration & Dispute Resolution
In the event that a disagreement arises, which we are not able to satisfactorily resolve between us, then client hereby agrees that any and all disputes, controversies, claims, or demands arising out of or relating to this agreement, our relationship with you, or our performance of any current or future healthcare services, will be resolved exclusively by submission to binding arbitration in Austin, Texas for resolution. This is for any and all disputes arising under or relating to this contract or the engagement and healthcare services to be rendered, including but not limited to malpractice claims or any others. Arbitration is to be conducted under the Texas Arbitration Act in accordance with the laws of the State of Texas. Arbitration costs will be allocated evenly among the involved parties. The arbitrator will have the authority to award any relief that a judicial court would have the jurisdiction to grant. The arbitrator will be permitted to award attorney’s fees as he or she deems necessary and just. Both IC and client intend and agree to be bound by this provision and the results of such arbitration. Client understands and agrees that it has the right to consult independent counsel regarding this provision and that if accepted, this provision will eliminate clients’ right to a jury trial in any and all disputes.
H. For clients under 18 years of age
The undersigned Legally Authorized Representative (LAR) attests that: I have read and understand the terms of this INFORMED CONSENT, WAIVER, RELEASE AND ASSUMPTION OF RISK AGREEMENT and unconditionally agree to its full terms, statements, warranties, notices, representations, waivers and releases on behalf of both me (and marital community, if any), and my child or ward. All such terms, statements, warranties, notices, representations, waivers and releases fully apply to my child or ward as if I was the activity participant/ client. I understand that, by signing this Consent, I am giving up important legal rights both on behalf of myself and my child or ward regarding potential rights and claims against IC. I have had sufficient opportunity to read this entire document. I have read and understood it, and I agree to be bound by its terms.
I. Emergency Treatment
LAR hereby gives my permission that the IC staff is authorized to give my child/ ward participant reasonable first aid, or if my child/ward should require emergency medical or surgical treatment, he/she may be treated at the nearest emergency facility by the physician in attendance and any other health care professionals to consult. I hereby authorize IC and their authorized representatives to disclose any of my child/ward's health-related information to any healthcare provider and I consent to the admission of the activity participant to the hospital, the administration and performance of all examinations and the administering of medicine, treatment, anesthetics, operations, x-rays or other procedures which the physicians attending the participant deem necessary for the emergency care and treatment of the participant. I hereby agree to accept responsibility for any financial indebtedness occurring in transport, in the emergency room, or clinic treatment of the participant at the emergency facility utilized. Further, I understand that, upon my arrival at the hospital, I will authorize continued medical care.
BY SIGNING, I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.
