INFORMED CONSENT FOR TREATMENT
LiveWell Psychiatry & Men's Health
Phone: 509-596-1138 | Fax: 971-308-7811
This Informed Consent for Treatment describes the nature of healthcare services provided
by LiveWell Psychiatry & Men's Health, the services offered, potential benefits and risks,
alternative treatment options, and your rights as a patient. Please review this document
carefully and ask questions about anything that is unclear before signing.
I. CONSENT TO TREATMENT
By signing this document, I voluntarily agree to receive healthcare services from LiveWell
Psychiatry & Men's Health and its affiliated providers. I understand that LiveWell facilitates
connections between independent healthcare professionals and patients, and that each
provider operates independently and is responsible for all aspects of my care. All clinical
services are provided by licensed or appropriately supervised practitioners.
II. DESCRIPTION OF SERVICES
LiveWell Psychiatry & Men's Health provides the following healthcare services:
A. Psychiatric and Mental Health Services
Psychiatric Evaluation and Diagnosis: Initial psychiatric evaluation involves a
comprehensive assessment of mental health symptoms, medical history, current
medications, psychosocial factors, and treatment needs. Based on this evaluation, a
psychiatric diagnosis may be assigned using standard diagnostic criteria (DSM 5 TR).
Evaluation typically requires 50 to 75 minutes.
Medication Management: Medication management involves the prescription, monitoring,
and adjustment of psychiatric medications to treat diagnosed mental health conditions.
Follow up visits typically occur every 1 to 3 months depending on clinical needs and
medication stability. Follow up visits range from 15 to 30 minutes.
Psychotherapy: Psychotherapy involves therapeutic conversations aimed at reducing
symptoms, improving coping skills, and addressing psychological difficulties. Various
evidence based modalities may be utilized. Psychotherapy sessions are typically 45 to 60
minutes.
B. Men's Health Services
Sexual Health and Performance: Evaluation and treatment of erectile dysfunction,
premature ejaculation, low libido, and other sexual health concerns. Treatment may include
prescription medications, shockwave therapy, lifestyle counseling, and referrals to specialists
when appropriate.
Hormone Therapy: Evaluation and treatment of testosterone deficiency and hormonal
imbalances. This includes laboratory testing, prescription of hormone replacement therapy
when medically indicated, and ongoing monitoring of treatment response and side effects.
Sexual Performance Enhancement: Optimization of sexual function through evidence
based medical interventions. This may include prescription medications, supplements,
shockwave therapy, light therapy, medical devices, and counseling on lifestyle factors
affecting sexual performance.
General Men's Health: Evaluation and management of health concerns specific to male
patients, including prostate health screening, male pattern hair loss, and other men's health
issues.C. Limited Primary and Preventive Care
Limited primary care services including routine health maintenance, management of chronic
conditions, preventive screenings, and acute minor illness care. LiveWell is not a
comprehensive primary care practice and complex medical conditions will be referred to
appropriate specialists.
D. IV Nutritional Therapy
Intravenous administration of vitamins, minerals, amino acids, and other nutrients for
hydration, wellness support, athletic performance and recovery, hangover recovery,
aesthetic and anti aging purposes. IV therapy is administered by trained medical staff under
provider supervision. Detailed information about IV therapy, including specific formulations,
risks, and benefits, is provided in the separate Consent for IV Therapy and Elective
Enhancement Procedures form.
E. Peptide Therapy
Peptide therapy involves the use of specific amino acid sequences to support various
biological functions. The following FDA approved peptide medications may be prescribed for
appropriate medical indications:
Semaglutide (Ozempic, Wegovy): FDA approved GLP 1 receptor agonist for type 2
diabetes management and chronic weight management in adults with obesity or overweight
with weight related medical conditions.
Tirzepatide (Mounjaro, Zepbound): FDA approved dual GIP and GLP 1 receptor agonist
for type 2 diabetes management and chronic weight management in adults with obesity or
overweight with weight related medical conditions.
Bremelanotide (Vyleesi, also known as PT 141): FDA approved for treatment of
hypoactive sexual desire disorder (HSDD) in premenopausal women. May be prescribed off
label for male sexual dysfunction based on clinical judgment and individual patient needs.
Tesamorelin (Egrifta): FDA approved for reduction of excess abdominal fat in HIV infected
patients with lipodystrophy. May be prescribed off label for other metabolic conditions based
on clinical judgment.
Additional Peptide Therapies: Other peptide therapies may be available depending on
treatment purpose, current medical and regulatory landscape, and individual patient needs.
All peptide therapies, whether FDA approved or compounded, require separate informed
consent with detailed discussion of specific risks, benefits, regulatory status, and off label
use where applicable. Your provider will discuss available options and regulatory status
during your consultation.
Peptides are typically administered via subcutaneous injection, though some are available in
other formulations. Your provider will discuss administration methods, storage requirements,
monitoring protocols, and potential risks specific to each peptide. Comprehensive
information about peptide therapy is provided in the separate Consent for IV Therapy and
Elective Enhancement Procedures form.
F. Functional Medicine and Performance Optimization
Comprehensive metabolic and hormonal assessment, nutritional optimization and
supplementation, lifestyle medicine and coaching, athletic performance enhancement, peak
performance and human optimization protocols, and preventive and proactive health
strategies. These services focus on optimization of health and function rather than treatment
of disease.
G. Aesthetic and Performance Enhancement ProceduresShockwave Therapy: Low intensity extracorporeal shockwave therapy for erectile
dysfunction, sexual function enhancement, tissue regeneration, and athletic recovery. Light
Therapy: Specific wavelength light therapy for various therapeutic and optimization
purposes. Medical Devices: Vacuum erection devices and pumps for therapeutic or
enhancement purposes. Body Composition Analysis: Advanced body composition
assessment and monitoring. Detailed information about these procedures is provided in the
separate consent form.
H. Participation of Students and Trainees
LiveWell participates in the training of healthcare professionals. Students, residents, and pre
licensed practitioners may be involved in your care under appropriate supervision by
licensed providers. All trainees are held to the same confidentiality and ethical standards as
licensed staff. All clinical decisions are reviewed and authorized by a supervising licensed
provider. By signing this consent, you acknowledge and agree to the participation of trainees
in your care.
III. POTENTIAL BENEFITS OF TREATMENT
Potential benefits of treatment may include:
• Reduction or elimination of symptoms
• Improved physical and mental health
• Enhanced ability to function in daily activities, work, and relationships
• Improved sexual function and satisfaction
• Optimized hormone levels and metabolic function
• Enhanced athletic performance and recovery
• Improved body composition and physical appearance
• Development of effective coping strategies and health behaviors
• Overall improvement in quality of life and peak performance
I understand that these benefits are potential outcomes and are not guaranteed. Individual
responses to treatment vary, and some patients may experience minimal or no benefit from
treatment.
IV. RISKS AND LIMITATIONS OF TREATMENT
A. Risks of Psychotherapy
Psychotherapy may involve risks including:
• Experiencing uncomfortable feelings such as sadness, anger, guilt, anxiety, or
frustration when discussing difficult life events
• Temporary increase in symptoms before improvement occurs
• Changes in personal relationships as you develop new insights and behaviors
• Treatment may not be effective for all individuals
B. Risks of Psychiatric Medications
All medications carry potential risks and side effects. Specific risks vary by medication class
and individual patient factors. Your provider will discuss medication specific risks prior to
initiating any prescription. General risks may include:
• Common side effects such as drowsiness, weight changes, gastrointestinal
symptoms, sexual dysfunction, or headaches
• Serious adverse reactions including allergic reactions, cardiovascular effects, or
metabolic changes
• Drug interactions with other medications, supplements, or substances
• Withdrawal symptoms if medication is discontinued abruptly• Medication may not be effective or may require multiple trials to find optimal
treatment
• Risk of medication dependence or misuse for certain controlled substances
FDA BLACK BOX WARNINGS: Certain medications carry FDA mandated black box
warnings for serious risks. Your provider will review all applicable warnings before
prescribing any medication. Common black box warnings include: (1) Antidepressants may
increase suicidal thinking and behavior in children, adolescents, and young adults up to age
24. (2) Antipsychotic medications may increase risk of death in elderly patients with
dementia related psychosis. (3) Benzodiazepines carry risk of abuse, dependence, and
serious withdrawal reactions. (4) Testosterone therapy may increase risk of cardiovascular
events including heart attack and stroke. (5) Medications for erectile dysfunction may cause
sudden vision or hearing loss or cardiovascular complications in patients with pre existing
heart conditions. (6) GLP 1 receptor agonists (semaglutide, tirzepatide) carry warnings about
thyroid tumors including medullary thyroid carcinoma in animal studies, and are
contraindicated in patients with personal or family history of medullary thyroid cancer or
Multiple Endocrine Neoplasia syndrome type 2. These are examples and do not constitute a
complete list. You will be informed of all applicable warnings for any medication prescribed
to you.
C. Specific Risks of Men's Health Treatments
Testosterone Replacement Therapy: May increase risk of blood clots, sleep apnea,
prostate enlargement, decreased sperm production, acne, fluid retention, elevated red blood
cell count, and cardiovascular events. Regular monitoring through laboratory testing and
clinical evaluation is required.
Erectile Dysfunction Medications: May cause headache, flushing, nasal congestion, visual
changes, dizziness, and in rare cases, priapism (prolonged erection requiring emergency
treatment). Contraindicated with nitrate medications due to risk of dangerous blood pressure
drop. May cause sudden vision or hearing loss.
Premature Ejaculation Treatments: May cause decreased libido, nausea, dizziness,
drowsiness, or other medication specific side effects.
D. Risks of Peptide Therapy
Peptide medications carry specific risks that will be discussed in detail before initiating
therapy. General risks include:
• Injection site reactions (redness, swelling, bruising, pain)
• Gastrointestinal symptoms (nausea, vomiting, diarrhea, constipation) especially with
GLP 1 medications
• Hormonal changes and metabolic effects
• Blood sugar fluctuations requiring monitoring
• Allergic reactions ranging from mild to severe
• Medication specific risks based on individual peptide prescribed
• Individual response varies and results are not guaranteed
Comprehensive risks for specific peptides will be provided in separate informed consent
documentation before initiating peptide therapy. Your provider will discuss the specific risks,
benefits, and regulatory status of any peptide medication recommended for your care.
E. Limitations of Services
LiveWell provides outpatient healthcare services and is not an emergency or crisis
intervention service. In the event of a medical or psychiatric emergency, life threatening
situation, or acute safety concerns, you should call 911, go to the nearest emergency
department, or contact the National Suicide Prevention Lifeline at 988. LiveWell providers
are not available for immediate crisis intervention outside of scheduled appointments.LiveWell offers limited primary care services and complex medical conditions will be referred
to appropriate specialists.
V. INFORMED CONSENT FOR MEDICATIONS
If medication is recommended as part of your treatment plan, your provider will discuss the
diagnosis or symptoms being targeted, the recommended medication including generic and
brand names, intended therapeutic effects and expected timeline for improvement, common
and serious side effects, necessary monitoring such as laboratory tests or vital signs, drug
interactions and contraindications, special warnings including FDA black box warnings, and
alternative treatment options.
I agree to take all prescribed medications as directed and to promptly report any concerning
side effects or adverse reactions to my provider. I understand that I am responsible for
requesting medication refills at least 5 business days before my supply is depleted to allow
adequate time for processing. I will not request early refills or replacement prescriptions for
controlled substances that are lost, stolen, or consumed more rapidly than prescribed,
except in rare circumstances and at the provider's discretion.
VI. ALTERNATIVE TREATMENT OPTIONS
Alternative treatment options exist for most medical conditions. Your provider can discuss
these alternatives with you. Possible alternatives include:
• Different medications or medication classes
• Psychotherapy with a different provider or modality
• Group therapy or support groups
• Intensive outpatient programs (IOP) or partial hospitalization programs (PHP)
• Inpatient hospitalization for severe symptoms
• Lifestyle modifications including diet, exercise, stress management, and sleep
hygiene
• Specialist referral for more intensive or specialized care
• Alternative or complementary treatments
• Choosing not to pursue treatment, though this option carries its own risks
I understand that I have the right to discuss these alternatives with my provider and to seek
treatment elsewhere if I choose.
VII. PATIENT RIGHTS AND RESPONSIBILITIES
A. Your Rights
• Right to refuse treatment: You have the right to decline any recommended
treatment without prejudice.
• Right to terminate treatment: You may discontinue treatment at any time.
• Right to ask questions: You have the right to ask questions about your diagnosis,
treatment, and prognosis.
• Right to informed consent: You have the right to receive adequate information to
make informed decisions about your care.
• Right to a second opinion: You may seek consultation with other providers.
• Right to privacy: Your health information is protected by state and federal privacy
laws.
Minors and Mental Health Treatment: Washington law allows minors aged 13 and older to
consent to mental health treatment independently. However, we encourage family
involvement when appropriate and may require parental consent for certain services
including controlled substance prescribing, depending on the clinical situation. Electiveoptimization services (IV therapy, peptide therapy, performance enhancement, aesthetic
procedures) are available to patients 18 years of age and older.
B. Your Responsibilities
• Provide accurate and complete information about your symptoms, medical history,
and medications
• Follow your treatment plan and take medications as prescribed
• Attend scheduled appointments or provide adequate notice of cancellation
• Report any changes in your condition, side effects, or concerns promptly
• Maintain financial responsibility for services rendered
• Contact emergency services (911 or 988) in the event of a crisis, as LiveWell is not
an emergency service
VIII. CONFIDENTIALITY AND MANDATED REPORTING
All communications between you and your provider are confidential and protected by state
and federal law, except in the following circumstances where disclosure may be required or
permitted: when there is reasonable suspicion of abuse or neglect of a child, elderly person,
or dependent adult; when you present an imminent risk of serious harm to yourself or others;
when required by a valid court order or subpoena; when you provide written authorization for
disclosure; or when otherwise required or permitted by law.
IX. ELECTRONIC HEALTH RECORDS AND COMMUNICATION
LiveWell utilizes a HIPAA compliant electronic health record (EHR) system for
documentation and communication. You may be provided access to a secure patient portal
(LiveWell Patient Portal, available at portal.livewellwith.us or via the LiveWell PHR app on
Apple App Store or Google Play Store) through which you can view portions of your medical
record, communicate with your provider, schedule appointments, and complete forms.
Response time for non urgent messages is typically 2 to 3 business days. Email and text
messaging are not secure methods of communication and should not be used for urgent or
confidential matters. For urgent clinical concerns, contact your provider through the patient
portal or call the office during business hours (10:00 AM to 7:00 PM Monday through Friday.
Individual clinicians have varying availability).
X. RECORDINGS AND AI ASSISTED DOCUMENTATION
LiveWell may utilize secure audio recordings during clinical sessions to facilitate clinical
documentation through HIPAA compliant AI transcription services. These recordings are
encrypted, stored securely, and automatically deleted following transcription. The recordings
are not shared with any third parties except the contracted HIPAA business associate
providing transcription services. You may not audio or video record sessions without prior
written consent from your provider.
XI. CCTV RECORDING IN OFFICE
The LiveWell office utilizes CCTV audio and video recording for safety and security
purposes. By entering the office, you consent to being recorded at all times while on the
premises. These recordings are stored securely and accessed only for safety, security, and
legal purposes as permitted by law.
CONSENT STATEMENT
By signing below, I acknowledge that I have read and understand this Informed Consent for
Treatment. I have had the opportunity to ask questions and all my questions have been
answered to my satisfaction. I understand the nature of the services provided, the potentialbenefits and risks of treatment, and alternative treatment options. I voluntarily consent to
receive healthcare services from LiveWell Psychiatry & Men's Health and its affiliated
providers.
NOTICE OF PRIVACY PRACTICES
LiveWell Psychiatry & Men's Health
Effective Date: January 1, 2026
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED
AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
I. OUR COMMITMENT TO YOUR PRIVACY
LiveWell Psychiatry & Men's Health is committed to protecting the privacy of your health
information. This Notice of Privacy Practices describes how we may use and disclose your
protected health information (PHI) to carry out treatment, payment, or healthcare operations,
and for other purposes permitted or required by law. It also describes your rights regarding
your health information.
We are required by law to maintain the privacy of your protected health information, provide
you with this notice of our legal duties and privacy practices, and notify you following a
breach of unsecured protected health information.
II. HOW WE MAY USE AND DISCLOSE YOUR HEALTH
INFORMATION
The following categories describe different ways we may use and disclose your health
information without your written authorization. Not every use or disclosure in a category will
be listed. However, all of the ways we are permitted to use and disclose information will fall
within one of these categories.
A. For Treatment
We may use and disclose your health information to provide, coordinate, or manage your
healthcare and related services. This includes consultation with other healthcare providers
regarding your treatment and referral to another provider for services. For example, we may
share your psychiatric medication list with your primary care physician to coordinate care
and prevent drug interactions.
B. For Payment
We may use and disclose your health information to obtain payment for services we provide
to you. For example, we may submit claims to your insurance company containing certain
health information, or we may contact your insurance company to determine whether a
service is covered. We may also disclose information to collection agencies if payment is not
received.
C. For Healthcare Operations
We may use and disclose your health information for our healthcare operations, which
include internal administration, quality assessment and improvement, credentialing, business
planning, and other operational activities. For example, we may use health information to
evaluate the performance of our staff, assess the quality of care, or conduct training
programs.
D. Other Permitted Uses and Disclosures Without Authorization
We may use or disclose your health information without your written authorization in the
following situations:• To Avert a Serious Threat to Health or Safety: When necessary to prevent a
serious and imminent threat to your health or safety or the health or safety of others.
• Business Associates: We may disclose health information to our business
associates who perform functions on our behalf or provide us with services if the
information is necessary for such functions or services. Our business associates are
required by contract to protect the privacy of your information and are not allowed to
use or disclose it for any purpose other than as specified in our contract.
• Organ and Tissue Donation: If you are an organ donor, we may release health
information to organizations that handle organ procurement or transplantation.
• Military and Veterans: If you are a member of the armed forces, we may release
health information as required by military command authorities.
• Workers' Compensation: We may disclose health information to the extent
necessary to comply with laws relating to workers' compensation or other similar
programs.
• Public Health Activities: We may disclose health information for public health
activities such as preventing or controlling disease, injury, or disability, reporting
births and deaths, reporting child abuse or neglect, or reporting adverse reactions to
medications.
• Health Oversight Activities: We may disclose health information to health oversight
agencies for activities authorized by law, such as audits, investigations, inspections,
licensure, or disciplinary actions.
• Lawsuits and Disputes: If you are involved in a lawsuit or dispute, we may disclose
health information in response to a court or administrative order, subpoena,
discovery request, or other lawful process.
• Law Enforcement: We may release health information if asked to do so by law
enforcement officials in response to a court order, subpoena, warrant, summons, or
similar process, or to identify or locate a suspect, fugitive, material witness, or
missing person.
• Coroners, Medical Examiners, and Funeral Directors: We may release health
information to a coroner or medical examiner to identify a deceased person or
determine the cause of death, or to funeral directors as necessary to carry out their
duties.
• National Security and Intelligence Activities: We may release health information
to authorized federal officials for intelligence, counterintelligence, and other national
security activities authorized by law.
• Inmates: If you are an inmate of a correctional institution or under the custody of law
enforcement, we may release health information to the correctional institution or law
enforcement official if necessary for your health or the health and safety of others.
• CCTV Recording: Our office utilizes CCTV audio and video recording for safety and
security purposes. These recordings may capture protected health information
incidentally. Recordings are stored securely and accessed only for safety, security, or
legal purposes as permitted by law. By entering our office, you consent to being
recorded.
E. Abuse, Neglect, or Domestic Violence
We may disclose health information to appropriate authorities if we reasonably believe that
you are a possible victim of abuse, neglect, or domestic violence, or if we believe you have
been the victim of other crimes. We may also disclose information if we believe it is
necessary to prevent serious harm to you or someone else. We will only make this
disclosure as required or authorized by law.
III. SPECIAL PROTECTIONS FOR CERTAIN TYPES OF
INFORMATIONA. Psychotherapy Notes
Psychotherapy notes are notes recorded by a mental health professional documenting or
analyzing the contents of conversation during a private counseling session. These notes are
kept separate from your medical record. Most uses and disclosures of psychotherapy notes
require your written authorization. However, we may use or disclose psychotherapy notes
without your authorization for our own training programs, to defend ourselves in a legal
action brought by you, or when required by law.
B. Mental Health Information
Mental health information receives additional protections under Washington state law (RCW
70.02). Generally, we must obtain your written authorization before disclosing mental health
information, except for treatment, payment, healthcare operations, or as otherwise required
or permitted by law.
C. Substance Use Disorder Information
Federal law (42 CFR Part 2) provides special privacy protections for substance use disorder
patient records. We cannot disclose that you have been a patient here or disclose any
information identifying you as having or having had a substance use disorder unless you
provide written consent or the disclosure is permitted by federal regulations. A general
authorization for the release of medical information is NOT sufficient. Federal law restricts
any use of the information to criminally investigate or prosecute any alcohol or drug abuse
patient.
IV. USES AND DISCLOSURES REQUIRING YOUR WRITTEN
AUTHORIZATION
Other uses and disclosures of your health information not covered by this notice or permitted
by law will be made only with your written authorization. Specifically:
• Marketing: We must obtain your authorization for most uses and disclosures of your
health information for marketing purposes.
• Sale of Health Information: We must obtain your authorization for any disclosure of
your health information that constitutes a sale of your information.
• Other Uses: Other uses and disclosures not described in this notice will be made
only with your written authorization.
You may revoke your authorization at any time by submitting a written revocation to our
office. However, the revocation will not affect any uses or disclosures already made in
reliance on your authorization.
V. YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION
You have the following rights regarding the health information we maintain about you:
A. Right to Request Restrictions
You have the right to request restrictions on certain uses and disclosures of your health
information. For example, you may request that we not disclose information to your family
members. We are not required to agree to your request, except in the case where you
request that we not disclose information to your health plan for payment or healthcare
operations purposes and you have paid for the service out of pocket in full.
B. Right to Request Confidential CommunicationsYou have the right to request that we communicate with you about your health information in
a particular manner or at a certain location. For example, you may request that we contact
you only at work or only by mail. We will accommodate reasonable requests.
C. Right to Inspect and Copy
You have the right to inspect and obtain a copy of your health information that may be used
to make decisions about your care, including medical and billing records. To inspect or copy
your health information, you must submit a written request. We may charge a reasonable,
cost based fee for copying and mailing records as permitted by state law. In certain limited
circumstances, we may deny your request to inspect or copy your records. If we deny your
request, you may request a review of that denial.
D. Right to Amend
If you believe that information in your health record is incorrect or incomplete, you have the
right to request that we amend the information. To request an amendment, submit a written
request that includes a reason for the request. We may deny your request if it is not in
writing, does not include a reason, or if the information is accurate and complete, was not
created by us, is not part of the information kept by or for us, or is not information you would
be permitted to inspect or copy.
E. Right to an Accounting of Disclosures
You have the right to request an accounting of certain disclosures of your health information
made by us during the six years prior to your request. This accounting will not include
disclosures made for treatment, payment, or healthcare operations, disclosures made to
you, disclosures made pursuant to your authorization, or certain other disclosures. To
request an accounting, submit a written request specifying the time period. The first
accounting in a 12 month period is free; for additional requests, we may charge a reasonable
fee.
F. Right to a Paper Copy of This Notice
You have the right to receive a paper copy of this Notice of Privacy Practices at any time,
even if you have previously agreed to receive it electronically. To obtain a paper copy,
contact our office.
G. Right to Notification of a Breach
You have the right to be notified in the event that we discover a breach of your unsecured
protected health information.
VI. OUR DUTIES
• We are required by law to maintain the privacy and security of your protected health
information.
• We are required to notify you following a breach of your unsecured protected health
information.
• We must follow the terms of the notice currently in effect.
• We will not use or disclose your health information without your written authorization,
except as described in this notice.
VII. COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint with our office
or with the Secretary of the U.S. Department of Health and Human Services. You will not be
retaliated against for filing a complaint.To file a complaint with our office:
Contact: Ragnar Scott, Practice Owner LiveWell Psychiatry & Men's Health Phone: 509-596-
1138 Email: [contact email]
To file a complaint with the U.S. Department of Health and Human Services:
Office for Civil Rights U.S. Department of Health and Human Services 200 Independence
Avenue, S.W. Washington, D.C. 20201 Phone: 1-877-696-6775 Website:
VIII. CHANGES TO THIS NOTICE
We reserve the right to change this notice and to make the revised or changed notice
effective for health information we already have about you as well as any information we
receive in the future. We will post a copy of the current notice in our office and on our
website. The notice will contain the effective date on the first page.
IX. CONTACT INFORMATION
If you have questions about this Notice of Privacy Practices, please contact: LiveWell
Psychiatry & Men's Health Ragnar Scott, Practice Owner Phone: 509-596-1138 Fax: 971-
308-7811
INFORMED CONSENT FOR TELEHEALTH SERVICES
LiveWell Psychiatry & Men's Health
Phone: 509-596-1138 | Fax: 971-308-7811
This Informed Consent for Telehealth Services provides important information about
receiving psychiatric care through telehealth technology. Telehealth involves the use of
electronic communications to provide healthcare services when the patient and provider are
in different locations. Please read this document carefully before agreeing to receive
telehealth services.
I. DEFINITION OF TELEHEALTH
Telehealth is the use of electronic information and telecommunications technologies to
support and provide healthcare services when the patient and healthcare provider are not in
the same physical location. LiveWell Psychiatry & Men's Health utilizes secure, HIPAA
compliant video conferencing technology through the LiveWell Patient Portal (available at
portal.livewellwith.us or via the LiveWell PHR app) to deliver psychiatric evaluation,
medication management, and psychotherapy services. Telehealth may also include
telephone consultations when video is not feasible, subject to limitations described below.
II. TECHNOLOGY REQUIREMENTS
To participate in telehealth services, you must have:
• A device with internet access (computer, tablet, or smartphone)
• A webcam and microphone (built in or external)
• A reliable internet connection
• Access to the LiveWell Patient Portal telehealth platform
You are responsible for ensuring you have the necessary technology and technical
capabilities to participate in telehealth appointments. Technical support for the telehealth
platform is available through the patient portal or by calling the office. LiveWell is not
responsible for technology failures on your end, including but not limited to internet
disruptions, device malfunctions, or platform access issues.
III. BENEFITS OF TELEHEALTH
Potential benefits of telehealth services include:
• Improved access to mental healthcare, particularly for patients in rural or
underserved areas
• Reduced need for travel and associated time and expense
• Ability to receive care from the comfort and privacy of your own home
• Continuity of care when in person visits are not feasible
• Flexibility in scheduling
IV. RISKS AND LIMITATIONS OF TELEHEALTH
A. Technical Issues
Telehealth services depend on technology that may fail or be interrupted. Issues that may
occur include poor internet connection, audio or video delays, frozen screens, dropped
connections, or platform malfunctions. In the event of a technical failure during a session,
your provider will attempt to reconnect or may contact you by telephone to complete the
session. If technical issues cannot be resolved, your appointment may need to berescheduled. You will not be charged for appointments that cannot be completed due to
technical failures on the provider's end.
B. Privacy and Security Risks
While the LiveWell Patient Portal uses encrypted, HIPAA compliant technology, no electronic
communication is completely secure. There is a small risk that information transmitted could
be intercepted or accessed by unauthorized parties. You are responsible for ensuring you
participate in telehealth sessions from a private location where others cannot overhear your
conversation. Do not participate in sessions while driving, in public spaces, or in other non
private locations.
C. Clinical Limitations
Telehealth has certain clinical limitations compared to in person care:
• The provider cannot perform a physical examination or observe certain physical
signs and symptoms
• Visual and audio quality may not be equivalent to in person assessment
• Some mental health conditions or situations may be better assessed and treated in
person
• Telehealth may not be appropriate for patients in acute crisis or requiring immediate
intervention
Your provider will assess whether telehealth is clinically appropriate for your specific
situation. If your provider determines that in person care is necessary, you will be informed
and appropriate arrangements will be made or referrals provided.
V. PRIVACY AND CONFIDENTIALITY
All privacy and confidentiality protections that apply to in person healthcare services also
apply to telehealth services. Your telehealth sessions are confidential and protected by state
and federal law. The LiveWell telehealth platform uses encryption and is fully HIPAA
compliant. Sessions are conducted through secure video connection and are not recorded
unless specifically agreed upon in advance for clinical documentation purposes.
Your responsibilities for maintaining privacy:
• Participate in sessions from a private location where you cannot be overheard
• Use headphones if there is any possibility of others overhearing
• Ensure that no one else is present in the room or can view your screen during the
session unless previously arranged with your provider
• Do not record sessions without explicit written permission from your provider
VI. EMERGENCY PROCEDURES AND LIMITATIONS
CRITICAL: Telehealth services are not appropriate for emergency situations. If you are
experiencing a psychiatric emergency, life threatening situation, or acute safety concern, you
must:
• Call 911 immediately, OR
• Go to the nearest emergency department, OR
• Call/text the National Suicide Prevention Lifeline at 988
At the beginning of each telehealth session, you will be asked to provide your current
physical location and confirm that you have access to emergency services at that location.
This information is necessary in the event your provider needs to contact emergency
services on your behalf.I understand that in the event of an emergency during a telehealth session, my provider may
need to contact emergency services (911) and provide my physical location to ensure I
receive immediate assistance.
VII. GEOGRAPHIC AND LICENSING RESTRICTIONS
IMPORTANT: You must be physically located in Washington or Oregon during all
telehealth appointments.
Healthcare providers are licensed to practice in specific states. LiveWell providers are
licensed in Washington and Oregon. Telehealth services can only be provided when you are
physically present in one of these states at the time of the appointment. You may not
participate in a telehealth session if you are located in any other state or outside the United
States.
If you will be traveling or temporarily located outside of Washington or Oregon, you must
inform your provider in advance so that alternative arrangements can be made. Your
provider reserves the right to terminate a telehealth session if you join from an unauthorized
location.
VIII. AUDIO ONLY TELEHEALTH SERVICES (TELEPHONE)
Under Washington state law (RCW 48.43.735), mental health services provided via audio
only technology (telephone) are permitted only if the patient has had at least one in person
appointment OR one real time appointment using both audio and video within the past three
years. Audio only services are not a substitute for video or in person care and will only be
utilized when video technology is unavailable or inappropriate for clinical reasons.
I understand that if I request or agree to audio only (telephone) services, I am attesting that I
have met the requirement of at least one in person or video visit within the past three years.
IX. PROVIDER TRAINING AND COMPETENCY
All LiveWell providers have completed mandatory telehealth training covering state and
federal law, professional liability, technology requirements, and informed consent procedures
as required by Washington state regulations. Providers maintain attestation of completion of
such training and ongoing education in telehealth best practices.
X. PAYMENT AND INSURANCE
Telehealth services are billed using the same fee schedule as in person services. Insurance
coverage for telehealth varies by plan. You are responsible for verifying your telehealth
benefits with your insurance company. If your insurance does not cover telehealth services,
you will be responsible for the full fee as outlined in the Clinic and Financial Policies. All
cancellation and no show policies apply equally to telehealth appointments.
XI. CONSENT TO PROCEED WITH TELEHEALTH
I understand that I have the right to refuse telehealth services at any time without affecting
my right to future care or treatment. I may request in person services if clinically appropriate
and available. I understand that telehealth does not expand my provider's scope of practice
beyond what is permitted by their license.
I have the right to expect the same quality of care through telehealth as I would receive
through in person services, within the inherent limitations of the telehealth modality. I have
the right to discontinue telehealth services and request in person care if I feel that telehealth
is not meeting my clinical needs.CONSENT STATEMENT
By signing below, I acknowledge that I have read and understand this Informed Consent for
Telehealth Services. I have had the opportunity to ask questions and all my questions have
been answered to my satisfaction. I understand the potential benefits, risks, and limitations
of telehealth services. I understand my rights and responsibilities as outlined above. I
voluntarily consent to receive psychiatric care through telehealth technology from LiveWell
Psychiatry & Men's Health.