Information collection As part of providing a telehealth psychological service to you, Remote Psych needs to collect and record personal information from you that is relevant to your situation, such as your name, contact information, medical history and other relevant information as part of providing psychological services to you. Your personal information is gathered as part of your assessment and treatment. As we will be working together remotely by videoconference, we need to be able to contact support people in your locality should any issues arise. You are required to provide the names and contact details of at least two people known to you before we commence treatment. Because you may be in varied locations for each of our sessions, we may require you to provide your location at the commencement of each session. Electronic and paper records are kept in secure storage and in the interests of your privacy, used only by your psychologist and the authorised personnel of the practice (as necessary). At any stage, you are entitled to access your personal information kept on file, subject to exceptions in the relevant legislation. Requests for information must be made in writing to the practice. If requiring further information in relation to information collection and storage this can be found here https://www.remotepsych.com.au/privacy-policy.  Disclosure of personal information All personal information gathered by the psychologist during the provision of the psychological service will remain confidential except when: 1.       it is subpoenaed by a court, or disclosure is otherwise required or authorised by law; or 2.       failure to disclose the information would, in the reasonable belief of the Remote Psych psychologist, place you or another person at serious risk to life, health or safety; or 3.       your prior approval has been obtained to disclose information. In the event that unauthorised access, disclosure or loss of a client’s personal information occurs, Remote Psych will activate it’s Data Breach Response Plan and use all reasonable endeavours to minimise any risk of consequential serious harm. Reporting requirements If receiving Better Access rebates or Medicare bulk billing, there are reporting requirements to your GP. At certain intervals, a report will be sent to your referring GP outlining the treatment undertaken, progress and any ongoing needs, together with recommendation of how these needs can be met. If you are receiving treatment funded by a third party such as your NDIS plan, Worker’s compensation or a TAC claim, your case manager or insurer may request a treatment and progress report, or similar. This report may also be required to approve further sessions. Online communications The privacy of any form of communication via the internet or a mobile device is potentially vulnerable and limited by the security of the technology. Zoom software is used for all Remote Psych videoconferencing and is secure and cloud hosted in Australia. Please be aware that email communication is not secure and should contain minimal personal information. Email will be used for administrative purposes primarily (such as setting up appointments and reminders). Invoices and receipts will be sent as email attachments (which can be password protected if desired). By providing information to us or our third-party-providers, you acknowledge that no transmission over the internet can be guaranteed as secure and is transmitted at your own risk. Use of therapy session materials Remote Psych will not make recordings of your sessions or use material from the sessions for purposes other than delivering a service to you. We will seek your consent if we wish to use material for other purposes (such as consultation with colleagues). We ask that you respect your psychologist’s privacy by agreeing not to make recordings of sessions or phone calls and not to use materials from the sessions for purposes other than therapy. If you wish to record sessions or use session material for other purposes, you must seek your clinician’s prior consent to do so. This includes the forwarding of written correspondence to third parties. Limitations of telehealth A telehealth consultation may be subject to limitations such as an unstable network connection which may affect the quality of the psychology session. In addition, there may be some services for which telehealth is not appropriate or effective. Your psychologist will consider and discuss with you the appropriateness of ongoing telehealth sessions. Please be aware that you are responsible for any costs incurred in relation to the provision of your own software, hardware and data usage associated with this telehealth service. System requirements and Security The use of our services requires a suitable device with internet access, certain software, and security. You should follow all security instructions and suggestions provided by your device’s manufacturer or system provider. You are liable for ensuring your device is locked and encrypted at all times, as well as installing all security and system updates as recommended or provided to you by your device’s manufacturer or system provider. All Personal Meeting ID (PMI) meetings will be passcode protected. Meeting passcodes will be encrypted and included in the invite link to allow clients to join with just one click without having to enter the passcode. Or, if you prefer and if pre-arranged, your psychologist can provide you with a unique Meeting ID and Passcode, generated for each consultation. Appointment Cancellations Your appointments and well-being are very important to us. When cancelling or rescheduling, we respectfully request that you provide at least 24 hours’ notice prior to your scheduled appointment. Appointments are in high demand, and your advanced notice will allow another client access to that session. Where less than 24 hours’ notice is provided, a cancellation fee of $40 will be charged in the unfortunate event that your session can not be filled. For any no-shows/DNA, a cancellation fee of $40 will be charged. This fee will be invoiced to you with payment due within 7 days. A copy of our Cancellation Policy can be requested at any time. Appointment Reminders To avoid missed appointments, your psychologist will confirm your next session day/time at the end of each session. We will also send you an appointment reminder via SMS (by default) or email, around 48 hours prior to your session time, asking you to confirm your appointment. Payment Fees per session are invoiced in advance, with payment required on the day of your session. Payment of invoices is via Electronic Funds Transfer (EFT) by default, using the account details on the invoice. Alternative payment methods include Medipass and PayPal as pre-arranged. A copy of our Fee Policy can be requested at any time. Medicare Rebates & Bulk-billing A valid Mental Health Treatment Plan or other MBS referral is required to access Medicare rebates/subsidised sessions and Bulk-billing, and eligibility is limited to the number of sessions available on your referral. If you have no available MBS sessions, sessions can be continued privately, at the private session rate. You agree that you are liable for the applicable session fee for the service provided to you. You agree that you will not receive a Medicare rebate if you are not eligible. You agree you are liable to pay the ‘Benefit Amount’ in the event that we are unable to process a Medicare bulk-bill claim. Record of Consent I have been provided with information about the service including the limitations to privacy and confidentiality. I have agreed that in circumstances where the psychologist is concerned about my welfare and is unable to contact me, permission is provided for the psychologist to contact the emergency contacts provided. I have read and understood the information in the Practice Information Sheet and this Consent Form. I have discussed any outstanding questions with the practice and/or psychologist prior to signing. I voluntarily give express consent and agree to the above conditions for the psychological service provided by the psychologist selected above, on behalf of Remote Psych. I agree with the site privacy policy terms and conditions. I I agree that I am liable for the applicable session fee(s) for the service(s) provided to me. I agree that I am liable to pay the ‘Benefit Amount’ in the event that Remote Psych is unable to process a Medicare bulk-bill claim on my behalf, for my session(s). In addition, I agree to receive SMS notifications, invoices, and other correspondence from Remote Psych by email communication.

Details of the telehealth consultation(s) to be claimed with Medicare: Clinical Psychologists: • Psychological therapy health service provided by telehealth attendance by an eligible clinical psychologist (COVID-19) MBS Item #: 91167 50+ minutes delivered by video conference Or MBS Item #: 91182 delivered by telephone. Benefit amount: $131.65 Provider name: (primary treating psychologist as selected above) Location: Remote Psych Date of service: as agreed Or Psychologists: • Focussed psychological strategies health service provided by telehealth attendance by an eligible psychologist (COVID-19) MBS Item #: 91170 50+ minutes delivered by video conference Or MBS Item: 91184 delivered via telephone. Benefit amount: $89.65 Provider name: (primary treating psychologist as selected above) Location: Remote Psych Date of service: as agreed Medicare Privacy note: Your personal information is protected by law, including the Privacy Act 1988, and is collected by the Australian Government Department of Human Services for the assessment and administration of payments and services. This information is required to process your application or claim. Your information may be used by the department or given to other parties where you have agreed to that, or where it is required or authorised by law (including for the purpose of research or conducting investigations). You can get more information about the way in which the department will manage your personal information here - https://www.servicesaustralia.gov.au/privacy-policy?context=1