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General Consent: I have been informed of and consent to the treatment that will be provided to me by Central Outreach Wellness Center (“COWC”) and its providers, as well as their assistants and other staff members. Specifically, I agree and acknowledge that I have read, or someone has read and explained to me, information regarding the below treatment, treatment modalities, medical testing, and/or procedures I am to receive, as may be determined to be medically necessary and/or appropriate by my provider(s), including the purposes, potential uses, limitations, risks associated with, alternatives to, and meanings of those treatments, medical testing, and/or procedures. I consent to the treatment, treatment modalities, medical testing, and/or procedures to be performed, as may be determined medically necessary and/or appropriate by my provider(s), including:

• Sexually transmitted infection (“STI”) testing and treatment. That testing and treatment for STIs may include: Human Immunodeficiency Virus (“HIV”), Hepatitis, Syphilis, Gonorrhea, and/or Chlamydia. I acknowledge that education and resources have been provided to me regarding prevention, prophylaxis, and treatment options that are available.
• Mental health evaluation and treatment by COWC’s Mental Health Services Department. That evaluation and treatment may involve diagnostic tests/procedures, including medical, laboratory, scans, and/or other tests, as may be determined to be medically necessary and/or appropriate by my provider(s). I also authorize release of information to the Poison Center, if required, as part of my treatment.

I understand and acknowledge that, insofar as I am seeking and/or receiving mental health care at COWC, certain information about my mental health will be accessible by my primary care provider(s)/team for collaboration of care and the administrative team for needs associated with provision of my healthcare. This includes access to mental health appointment dates/times, modalities and frequency of treatment, mental health evaluation and progress notes, symptoms, diagnoses, and medications prescribed, clinical tests ordered and results, functional assessment(s), and treatment plans.

Consent to Collaborative Care: I consent, where determined to be medically necessary and/or appropriate by my provider(s), to receive collaborative care services through COWC. It has been explained to me, and I understand, that participating in collaborative care services through COWC shall involve consultation between my primary care provider, mental health provider, and relevant specialists, including a psychiatric consultant. I understand and acknowledge that cost-sharing applies to both ‘face-to-face,’ and ‘non-face-to-face,’ collaborative care services, even where supplemental insurer covers cost-sharing., and I agree to be responsible for any co-payments. Billing dates may vary between individual insurance plans. Dates of billing may not reflect dates of patient service due to psychiatric review necessary for participation in collaborative care services.

Telehealth Services: I consent, where determined to be appropriate by my provider, to receiving the health care services provided to me by COWC through telehealth. I agree and acknowledge that the benefits and risks associated with receiving those health care services through telehealth have been explained me, including, but not limited to:

• Increased access to care and convenience;
• Security concerns (e.g., data breaches, unauthorized access to patient data, and ransomware);
• Confidentiality concerns (e.g., breaches of confidentiality by unauthorized persons, potential lack of private space) ;
• Inability to gain access to all information that may otherwise be available in-person.
• Issues related to technology (e.g., technological problems which might interrupt or stop a visit before the expected or anticipated end time); and
• Safety Planning for crisis management and intervention concerns.

I understand and acknowledge that while COWC will make every effort to keep my information private, there is an inherent risk that electronic communications may be compromised, unsecured, or accessed by others. I will take reasonable steps to ensure the security of my communications with COWC (for example, only using secure networks for telehealth and using password protected devices for telehealth). Telehealth sessions will not be recorded without written agreement by all parties.

The provider and patient will decide together which kind of telehealth service to use. I understand that I am solely responsible for any cost to obtain any necessary data services, equipment, accessories, or software to engage in telehealth. COWC/my provider may decide that I still need an office visit. Certain medications require lab monitoring and/or face to face contact.

I understand and acknowledge that I may request that telehealth-based services be discontinued at any time. If I refuse the delivery of healthcare services through telehealth, this will not affect my right to care or treatment.

Assessing and evaluating threats and other emergencies can be more difficult when conducting telehealth sessions than in traditional in-person mental health treatment. To address some of these difficulties, the provider and the patient will create a safety plan at the start of telehealth services. The provider will ask the patient to identify an emergency contact person who is near the patient’s location and who the provider will contact in the event of a crisis or emergency to assist in addressing the situation. The provider will ask the patient to sign a release of information form allowing the provider to contact the patient’s emergency contact person as needed during such a crisis or emergency. If the session is interrupted for any reason, such as the technological connection fails, and the patient is having an emergency, do not call the provider back; instead, call 911, 988, or the Resolve Crisis Line or go to the nearest emergency room. Call the provider back after the patient has called or obtained emergency services.

Use and Disclosure of Health Information: I understand and agree that COWC, its employees, and health care providers, will use and disclose my health information, in order to:

• Make informed decisions, refer to, consult with, coordinate among, and manage my health information regarding my medical care and treatment;
• Determine my eligibility for patient assistance programs, specialty pharmacy services, health plan benefits or insurance coverage;
• Coordinate with my insurance provider or other parties, who may be responsible, to field claims concerning billing, laboratory services, prior authorizations, and other medical benefits;
• Perform various office, administrative, and business functions that support my medical providers’ efforts to provide me with quality, culturally competent, cost-effective health care.
• At my request, assist me in setting up appointments for medical specialists, CT scans, other medical testing, or any other healthcare system follow-up.
• I voluntarily and knowingly release Central Outreach Wellness Center, its affiliates, employees, and healthcare providers from any responsibility or liability of any kind from any of the above activities, including any delays in scheduling appointments or obtaining test results.

I understand that my health information may include details that pertain to: health history and status, symptoms, examination, testing, diagnosis and treatment plan, procedures, prescriptions, etc.; may exist in entries created and/or received by the practice; and may exist in written, spoken, or electronic forms.

I acknowledge that, as a patient at COWC, under the direction of Dr. Stacy Lane, DO, that I am authorizing COWC, Dr. Stacy Lane, and all health care providers, to speak on my behalf to any and all entities (including specialty pharmacies, physicians, etc.) in the management of my health care. Furthermore, I waive the right to be counseled by any pharmacy and I authorize Dr. Stacy Lane, and all other Central Outreach Wellness Center healthcare providers to direct all aspects of my health care.

Psychotherapy Notes: I understand that information divulged in counseling sessions with my provider-therapist will be more strictly confidential, accessible only to the mental health services team, and more limited information will be available to administrative personnel for provision of care. Counseling sessions will be documented in restricted ‘psychotherapy notes,’ by my therapist, which will convey the contents of conversation during these private sessions or a group, joint, or family counseling session.

COWC must obtain authorization for any use or disclosure of psychotherapy notes, except to carry out the following treatment, payment, or health care operations:

• Use by the originator of the psychotherapy notes for treatment;
• Use or disclosure by COWC for its own training programs in which students, trainees, or practitioners in mental health learn under supervision to practice or improve their skills in group, joint, family, or individual counseling;
• Use or disclosure by COWC to defend itself and/or its staff (where appropriate) in a legal action or other proceeding brought by me (or a representative);
• To ensure my safety or the safety of others in situations when imminent physical harm is stated or inferred to the provider-therapist.
• To report child or elder abuse in accordance with applicable state and/or federal law.

I acknowledge the above statements in regard to the privacy practices within COWC. I understand that I reserve the right to review how COWC handles my health information, in regard to use and disclosure. I understand that I have the right to ask that some or all of my health information not be used or disclosed in the manner described above; however, I understand that COWC is not required by law to agree to such a request.

Communication between COWC and Patient: I consent to have COWC communicate with me via email, text message, and/or Facebook messenger regarding my medical care and treatment. I understand that this type of correspondence may not be a confidential method of communication. I further understand that there is a potential risk that this communication between the medical office and myself, the patient, regarding my health information, may be intercepted by third parties or transmitted to unintended parties. I understand that in an urgent or emergent situation, I should call my provider directly or proceed to the Emergency Department; therefore, not solely rely on this type of communication.

Understanding of No-Recording Policy: I acknowledge that it is the policy of COWC that patients not record their encounters with medical providers and staff, including in patient rooms, so as to encourage honesty and candor in the patient-provider relationship, which is vital to ensuring patients receive the highest quality of care. I understand the importance of and agree to adhere to the COWC no-recording policy.

Patient Access to Health Records: I acknowledge my right of access to inspect and obtain a copy of my protected health information for as long as protected health information is maintained at COWC, except as it relates to the following records: psychotherapy notes, psychiatrist evaluations, progress notes, or other mental health notes if the interdisciplinary team determines and documents that disclosure would be detrimental to the patient.

Release of Information: I authorize COWC to release to insurance companies, claims processors, my primary care physician and other treating physicians, information regarding my treatment, hospitalization, and/or outpatient care which may include: mental health care, drug and/or alcohol abuse, and/or tests for diagnosis of HIV or acquired immunodeficiency syndrome (“AIDS”).

Authorization of Payment: I hereby authorize payment directly to COWC for the insurance benefits otherwise payable to me but not to exceed the balance. I understand I am financially responsible to COWC for charges not covered by my insurance. I understand that copayments may be paid at time of service or when a formal bill is received after service. Payment assistance is available to those who qualify. Please bring your bill and inquire at COWC if you are unable to afford your out-of-pocket costs.

Updating Insurance Information: I understand and acknowledge that it is my responsibility to provide COWC with correct insurance information at each visit so that it may be billed properly, and that failure to do so may result in a bill for services from these visits.

Self-Pay: I understand and acknowledge that I am financially responsible to COWC for all charges. Payment assistance is available to those who qualify. Please bring your bill and inquire with COWC if you are unable to afford your out-of-pocket costs.

Third-Party Lab Fees: I understand and acknowledge that I am fully responsible for any third-party lab fees associated with any care or services provided to me by COWC.

Medicare Certification: I certify that the information given by me in applying for payment under Title XVII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Centers for Medicare and Medicaid Services or its Intermediaries or carriers any information needed to determine these benefits for me, or on my behalf for any services furnished to me by Central Outreach Wellness Center. I request that payment of authorized MEDIGAP benefits be made either to me or on my behalf to Central Outreach Wellness Center for any services furnished to me by that physician/supplier. I authorize any holder of Medicare information about me to release to Health Care Financing Administration or its agents, any information to determine these benefits payable for related services.

Medicaid Certification: I certify that the information given by me on this consent is true, complete, and accurate. I understand that payment and satisfaction of the claim that I am incurring will be from Federal and State funds, and that any false claims, statements or documents or concealment of material facts may be prosecuted under federal or state laws. I am also aware that there are certain deductible/copayments on most Medicaid services and that I am liable to pay those deductible/copayments to the above-named providers.

Acknowledgment of Patient Rights: I acknowledge my rights as a patient; which have been displayed upon entry into the office and are available to me upon request. I understand that any health information form for inter or intra-office use may be revised from time to time and that I am entitled to receive a copy of any revised forms.

Consent to Release of Medical Records: Central Outreach Wellness Center is part of an organized health care arrangement including participants in OCHIN. A current list of OCHIN participants is available at www.ochin.org as a business associate of Central Outreach Wellness Center OCHIN supplies information technology and related services to Central Outreach Wellness Center and other OCHIN participants. OCHIN also engages in quality assessment and improvement activities on behalf of its participants. For example, OCHIN coordinates clinical review activities on behalf of participating organizations to establish best practice standards and assess clinical benefits that may be derived from the use of electronic health record systems. OCHIN also helps participants work collaboratively to improve the management of internal and external patient referrals. Your personal health information may be shared by Central Outreach Wellness Center with other OCHIN participants or a health information exchange only when necessary for medical treatment or for the health care operations purposes of the organized health care arrangement. Health care operations can include, among other things, geocoding your residence location to improve the clinical benefits you receive. The personal health information may include past, present and future medical information as well as information outlined in the Privacy Rules. The information, to the extent disclosed, will be disclosed consistent with the Privacy Rules or any other applicable law as amended from time to time. You have the right to change your mind and withdraw this consent; however, the information may have already been provided as allowed by you. This consent will remain in effect until revoked by you in writing. If requested, you will be provided a list of entities to which your information has been disclosed.

Consent to Release of Medical Records (UPMC) (where applicable):

I authorize UPMC to electronically provide my Electronic Medical Record to Health Information Exchanges as described below:

To: Central Outreach Wellness Center; Medical Records Provider: All Providers Phone: (412) 515-0000 Facility Address: 127 Anderson St. Pittsburgh, PA 15212

My Electronic Medical Record contains information that UPMC or participants in the UPMC MedChart - EpicCare Community Health Record have created through the course of providing treatment to me. My Electronic Medical Record may also contain information that UPMC may have received from other sources such as healthcare providers, physicians, lab, etc. My Electronic Medical Record includes such things as

• Physician Office/Clinic Visits and Consults
• Outpatient Summaries
• Inpatient Discharge summaries and instructions
• Emergency Department Reports
• Behavioral Health Information
• Physician Orders
• Medication Records
• Laboratory Reports/Tests
• Abortion & Reproductive Health Information
• HIV Relation Information
• Drug & Alcohol Information
• Genetic Information (including tests)
• Pathology Reports
• Radiology Reports
• EKG Reports
• Operative Reports

Health Information Exchange (HIE) allows doctors, nurses, pharmacists, other health care providers and health plans to appropriately access and securely share you vital medical information electronically improving the speed, quality, safety and cost of your care. A list of Health Information Exchanges UPMC participates in and UPMC MedChart-EpicCare Community Health Record participates may be found at https://www.upmc.com/patients-visitors/privacy-info/notice-of-privacy-practice. April 2025

I understand and agree to the following: I have read this Authorization or have had it read to me. This authorization allows for UPMC to release all or part of my Electronic Medical Information as described in this Authorization. This Authorization is valid for one (1) year from the date that I sign it.

Yes, I have read this: (Please check here if you are 13 years of age or older).

Yes, I have read this: Please Check here if you are a Patient, Legal Guardian, or Authorized Representative* (If the patient is under 18 years old and not emancipated, a Parent, Legal Guardian or Authorized Representative must sign in addition to the patient, except for information associated with services the minor is able to independently consent for.)

Additional Patient Rights and Responsibilities

This authorization may be revoked by notifying the UPMC Physicians Services Health Information Management Department by email PSDDataQuality@upmc.edu or by US mail to UPMC Physicians Services Health Information Management Department, Forbes Tower, Suite 9029, 200 Lathrop Street, Pittsburgh PA 15213. Questions may be directed to the department by phone at 412-864-1221. However, any revocation shall only present the release of my Electronic Medical Information after the date of the revocation.

I acknowledge that I have read, or have had read to me, this Consent to Treatment, Release, and Acknowledgement form and fully understand its contents. This Consent to Treatment, Release, and Acknowledgment form shall apply to all COWC facilities.

I understand and agree that COWC, its employees and healthcare providers, will use and disclose my healthcare information in order to: (1) make informed decisions, refer to, consult with, coordinate among and manage my health information regarding my medical care and treatment; (2) determine my eligibility for PrEP and PEP treatments and medication, patient assistance programs, specialty pharmacy services, health plan benefits or insurance coverage; (3) coordinate with my insurance provider or other parties who may be responsible to file claims concerning billing , laboratory services, prior authorizations and other medical benefits; and (4) perform various office, administrative and business functions that support my medical providers’ efforts to provide me with quality, cultural competent, cost effective healthcare.

I understand that my health information may include details that pertain to health history and status, symptoms, examination, testing, diagnosis, and treatment plans including PrEP and PEP treatments, procedures, prescriptions, etc. I understand that my health information may exist in formats created and/or received by COWC; and may exist in written, spoken, or electronic forms.

I consent to have COWC communicate with me via the telemedicine procedures currently used by COWC, email, text message, and/or Facebook messenger regarding my medical care and treatment. I understand that in some instances this correspondence may not be a confidential method of communication. I further understand that there is a potential risk that this communication between COWC, its employees and healthcare providers, and myself, the patient, regarding my health information may be intercepted by third parties or transmitted to unintended parties. I understand that in an urgent or emergent situation, I should contact my healthcare provider directly or proceed to the Emergency Department and therefore am not solely relying on this type of communication.

I understand that I reserve the right to review how COWC handles my health information, in regard to use and disclosure. I understand that I have the right to ask that some or all of my health information not be used or disclosed in the manner described above; however, I understand that COWC is not required by law to agree to such a request.

I acknowledge, as a patient of COWC under the direction of Dr. Stacy Lane DO, that I authorize COWC, Dr. Stacy Lane, DO and all health care providers at COWC, to speak on my behalf to any and all entities (including specialty pharmacies, physicians, etc.) in the management of my healthcare. Furthermore, I waive the right to be counseled by any pharmacy and I authorize Dr. Stacy Lane, and all other COWC healthcare providers to direct all aspects of my healthcare.

I acknowledge my rights as patient; which have been provided to me and are available to me upon request. I understand that any health information form for inter-office or intra-office use may be revised from time to time and that I am entitled to receive a copy of any revised forms.

Intending to be legally bound hereby, the Applicant or the Applicant’s authorized representative has executed this Telemedicine Informed Consent and HIPAA Consent.