Informed Consent & Provider Policies

Clinical Informed Consent & Provider Policies

Effective: March 2, 2019 | Revised: July 14, 2026 | Nationwide

Welcome to Modyfi®

Thank you for choosing Modyfi for your mental health and wellness needs. Founded in 2019, Modyfi stands for mind-body, functional, and integrative medicine, reimagining the mental healthcare experience with an individualized, holistic approach. We emphasize sustainable change, collaboration, and evidence-based care while identifying and addressing the root causes of mental health challenges.

Modyfi operates as a nationwide telehealth practice. Our core values include:

• Acceptance of people as they are
• Collaboration and teamwork
• Identifying and treating the root cause of issues
• Using science and evidence to guide care
• A willingness to challenge comfort zones for personal growth
• Offering individualized treatment options

We will continually assess progress and outcomes, adjusting your treatment plan as needed to ensure effective care.

Treatment Options & Medical Necessity

Modyfi directly provides the following services, all deemed medically necessary in that they address a covered diagnosis and are expected to improve that condition based on clinical evidence:

• Psychiatry and medication management
• Individual and couples psychotherapy (talk therapy)
• Nutrition and exercise therapy

Some services — including nutrition therapy, exercise therapy, psychotherapy, and specialty groups — are available through Modyfi Network providers. See the Modyfi Network & Care Coordination section and modyfihealth.com/providers for more information.

Telehealth Services

Modyfi offers telehealth-only services. By engaging in services, you acknowledge and consent to the following:

• Sessions are conducted via secure, HIPAA-compliant video platforms. You are responsible for ensuring you are in a private, confidential location during sessions.
• Technology failures may occasionally interrupt sessions. Your provider will make reasonable efforts to reconnect or reschedule.
• Modyfi ensures that all providers are appropriately licensed in the states where they deliver care. Licensing and regulatory compliance is managed through Modyfi’s credentialing processes.
• Telehealth may not be appropriate for all clinical situations. Your provider will advise you if in-person care is clinically recommended and assist with appropriate referrals.
• You consent to receiving care via telehealth and understand it carries the same rights and responsibilities as in-person care.

AI & Technology Use

Session Recording & AI-Assisted Note-Taking

With your consent, Modyfi providers may use AI-assisted tools to record and transcribe sessions for the purpose of generating clinical notes. Any AI tool used for this purpose must be covered by a valid HIPAA-compliant Business Associate Agreement (BAA) prior to use.

Regarding AI-assisted note-taking, you should know:

• Sessions may be recorded via audio or video for the sole purpose of generating a transcription and clinical notes.
• All AI-generated notes and transcriptions are reviewed, edited, and approved by your licensed Modyfi clinician before becoming part of your official health record. AI does not make independent clinical decisions.
• Recordings used for transcription are not retained beyond what is operationally necessary for transcript and clinical note generation and are not stored as standalone audio or video files in your patient record.
• You may opt out of AI-assisted recording and note-taking at any time, including on a per-appointment basis, by notifying your provider at the start of your session. Opting out will not affect the quality of your care.

AI-Assisted Clinical Data Review

Modyfi may use AI tools operating within HIPAA-compliant platforms under active BAAs to support clinical data review and care coordination. This may include review of clinical summaries, treatment notes, and relevant health information to improve care quality and support clinical decision-making. All AI-assisted data review is subject to licensed clinician oversight.

What AI Does Not Do

• AI tools do not make diagnoses or treatment decisions independently.
• AI-generated content does not enter your health record without clinician review and approval.
• Your data is not used to train AI models or shared with third parties for commercial purposes.

Crisis & Emergency Protocol

Modyfi is not an emergency clinic and does not have staff available after hours.

• Call 988 for mental health emergencies.
• Call 911 or go to the nearest emergency room for life-threatening situations.
• Ask the attending provider to contact your Modyfi clinician for continuity of care.
• For non-crisis and emergency matters during office hours, call or text 833-366-3934.

Disability & Paperwork Policy

Modyfi contracts with Formacist® to complete short-term disability, FMLA, ADA accommodations, and various other letters and forms. Providers are not legally required to complete disability paperwork or accommodation requests and retain clinical discretion in determining whether such documentation is appropriate. For more information, visit modyfihealth.com/formacist.

High Complexity ($150 first hour, $100 per additional hour)

• Workplace Accommodation Request (Federally Protected, Employer-Approved)
• Educational Accommodation Request (Federally Protected, School-Granted)
• Intermittent FMLA Request (Unpaid, Federally Protected)
• Intermittent Leave Request (Unpaid, Employer-Approved)
• Continuous Short-Term Disability Leave Request (Paid, Employer-Approved)
• Continuous FMLA Leave Request (Unpaid, Federally Protected)
• Continuous Medical Leave Request (Unpaid, Employer-Approved)

Moderate Complexity ($60)

• Return-to-Work or Return-to-School Clearance
• Emotional Support Animal Letter
• Letter of Support
• Medical Leave of Absence Letter
• Health Status Statement
• Modified Duty Recommendations
• Workplace/School Release Letter
• Therapy Attendance Verification

Simple Complexity ($30)

• Confirmation of Treatment

Transition of Care & Medical Records

Patients are responsible for any expenses related to transferring medical records. Under the CARES Act of 2021, patients may access their medical records at no charge. Psychotherapy notes are protected by law and are excluded from this general access right.

Insurance & Payment Policies

• Modyfi Health does not currently contract and thus is not able to accept Medicaid or Medicare for its direct psychiatric services.
• Some Modyfi Network providers may accept Medicaid, Medicare, or other insurance plans. Please verify coverage directly with your Network provider.
• Insurance coverage varies by provider and state. We recommend calling your insurance company before scheduling to verify coverage.
• Modyfi does not offer sliding scale fees for direct services. If you are unable to afford self-pay, we suggest exploring insurance options through HealthCare.gov.
• Payment plans are offered to patients through CareCredit. For more information, visit modyfihealth.com/carecredit.
• Patients are ultimately responsible for all charges and fees for Modyfi direct services.

Payment Policies for Modyfi Direct Services

• A valid payment method is required on file at all times. You cannot see your provider without active payment information on file.
• All major credit cards, including FSA/HSA, are accepted.
• Self-pay clients must prepay for sessions.
• Copays and unpaid self-pay fees will be collected 48 hours before your scheduled appointment.
• Refund Policy: If you cancel at least 24 business hours before your appointment, a full refund will be issued. Cancellations within 24 business hours are treated as no-shows.
• Any owed copayments, coinsurance, or uncovered service fees will be charged to your payment method on file at the time of service if not already collected.
• Payment plans are available for large balances. Contact maps@modyfihealth.com to arrange a plan.
• Past due balances over 180 days may be referred to collections with additional fees.
• If you are experiencing financial hardship, contact us at maps@modyfihealth.com before your balance becomes past due.

Late Arrivals, Early Terminations, Late Cancellations & No-Shows

Automated reminders are a courtesy; attending your appointment is your responsibility.

No-Shows — Psychiatry

• More than 10 minutes late to a 30-minute session = $100
• More than 20 minutes late to a 60-minute session = $150

Late Cancellations

• Appointments must be canceled or rescheduled at least 24 business hours in advance.
• Cancellation within 24 business hours = treated as a no-show.

Early Termination — Psychiatry

• Less than 56 minutes of a 60-minute session = $50
• Less than 20 minutes of a 30-minute session = $30

Late Arrival — Psychiatry

• 5 or more minutes late for a 60-minute session = $50
• 10 or more minutes late for a 30-minute session = $30

Minors, Custody & Parental Consent

• Modyfi does not perform custody evaluations or testify on custody-related matters unless court-compelled.
• Parents are expected to coordinate appointments, transportation, and care logistics independently. Clinicians cannot act as messengers between parents.
• Both parents generally retain equal access to a minor child’s records unless parental rights have been formally revoked by a court.
• Progress and safety updates may be shared with guardians; full session content may not be disclosed.

Minor Consent

The age of majority and minor consent laws vary by state. Patients aged 18 and older may consent to treatment independently in all states. In certain states, minors may consent to specific types of mental health treatment based on their circumstances, including emancipation, marriage, or the nature of the presenting concern. Modyfi applies the consent standards applicable to the patient’s state of residence and individual circumstances.

Parental Consent for Psychiatric Medication in Minors

• Both parents or legal guardians with shared medical decision-making authority must consent to the initiation or significant changes to a minor’s psychiatric medications, unless a court order specifies otherwise.
• In cases of shared custody, Modyfi will require documentation of custody arrangements and medical decision-making authority before initiating or modifying medications.
• Modyfi providers will not adjust a minor’s medications based on one parent’s instruction alone when the other parent’s authorization status is unclear or disputed.
• If a court order restricts one parent’s medical decision-making authority, a copy of that order must be provided to Modyfi before treatment proceeds.
• Emergency situations involving immediate safety risk will be handled in accordance with applicable state law and clinical best practices.

Legal Guardian Obligation

A parent or legal guardian must be present for telehealth sessions involving a minor patient unless the minor is legally authorized to consent independently under applicable state law. Absence of a required guardian will result in appointment cancellation and a no-show fee.

Supervision of Services

Some Modyfi providers may be delivering care under clinical supervision as part of their professional licensure requirements. Note that Modyfi’s psychiatric nurse practitioners (NPs) are independently licensed clinicians who do not require clinical sign-off on notes, though consultation on complex cases may occur collaboratively. By engaging in services at Modyfi where supervision applies, you:

1. Consent to supervision of services.
2. Consent to possible session recordings reviewed by clinical supervisors for supervisory purposes only.
3. Consent to sharing relevant session information with assigned clinical supervisors.

Legal Requests & Subpoenas

• Providers do not testify or provide court-related documentation unless court-ordered.
• If court-ordered, a $3,000 retainer is required per testifying provider prior to any related services. Unused retainer fees will be refunded.
• Patients will be notified before anticipated costs are expected to exceed the retainer amount.
• Rates: $350/hour for in-office work; $500/hour for out-of-office or court appearances; $2,000/day minimum for court appearances, plus travel and incidentals.

Controlled Substances & Prescription Policy

Controlled Substances via Telemedicine

Due to evolving federal regulations, Modyfi currently prescribes Schedule II–V medications via telemedicine. This policy is subject to change based on federal and state regulatory updates. If regulations change, Modyfi will implement contingency plans and notify affected patients.

Benzodiazepines & Stimulants

• Benzodiazepines (e.g., Xanax, Klonopin) are used for acute anxiety management but are rarely prescribed long-term due to the risk of tolerance and dependence.
• Stimulants (e.g., Adderall, Ritalin) are only prescribed after ruling out alternative explanations for focus, motivation, or hyperactivity concerns.

Substance Use Disorder Records — 42 CFR Part 2

Medication Refills

• Patients must have follow-up appointments at least every 90 days for medication continuation.
• Refill requests require at least 3 business days’ notice and are handled on a case-by-case basis.
• All controlled substances must be filled at a single designated pharmacy.
• Refill requests must be submitted via the refill request form at modyfihealth.com/refill-request.

Modyfi Network & Care Coordination

Modyfi operates a collaborative care network of credentialed providers (“Modyfi Network”), including independent practitioners, affiliated clinics, and partner organizations. A current directory of Modyfi Network providers is available at modyfihealth.com/providers.

The Modyfi Network enables warm referrals, coordinated treatment planning, and continuity of care across disciplines. Collaboration occurs through HIPAA-compliant platforms under active Business Associate Agreements.

By signing this consent, you acknowledge that your care may involve coordination with Modyfi Network providers. The specific categories of information that may be shared, your rights, and the authorization process are detailed in the Modyfi Network Data Sharing Authorization, which you will be asked to review and sign separately.

HIPAA Privacy Practices

This Notice describes how Protected Health Information (PHI) about you may be used and disclosed at Modyfi®. We are required by law to maintain the privacy of your health information, provide this Notice, and follow the terms described herein. For our full Privacy Practices, visit modyfihealth.com/privacy-practices.

Use & Disclosure of PHI

• Treatment – To provide and coordinate your care, including sharing with Modyfi Network providers under a valid authorization.
• Payment – For insurance billing and reimbursement, as applicable.
• Health Care Operations – Internal planning, quality review, and administrative functions.
• Public Health & Safety – Reporting of communicable diseases, abuse, neglect, or threats to health and safety as required by law.
• Legal & Law Enforcement – When required by court order or applicable federal or state law.
• Health Oversight & Special Government Functions – Ensuring compliance with applicable regulations.

Substance Use Disorder Records

Records related to substance use disorder treatment carry heightened federal protection under 42 CFR Part 2 and require your explicit written consent for each disclosure, even within a treatment team. See the Controlled Substances section above for more detail.

Care Team Coordination

By agreeing to this consent, you authorize Modyfi Health to communicate and coordinate care with other healthcare providers involved in your treatment, including referring providers and Modyfi Network providers, when clinically appropriate. Only the minimum necessary information will be shared, for treatment purposes only. You may revoke this authorization at any time in writing.

Your Rights Regarding PHI

• Right to Access & Copy Your Records – You may request access to or copies of your health records.
• Right to Request Confidential Communications – You may request alternative means of communication.
• Right to Restrict Disclosures – You may request restrictions on certain uses of your information.
• Right to Amend Your Records – You may request corrections to inaccurate information.
• Right to File a Complaint – Contact Modyfi at 833-366-3934 or clinic@modyfihealth.com. You may also file a complaint with the U.S. Department of Health and Human Services without retaliation.

SMS & Text Message Communication

Modyfi uses SMS text messaging for appointment reminders, care coordination, clinical follow-up, and administrative communications through HIPAA-compliant platforms under a BAA. SMS consent is voluntary and separate from this consent. You may opt out at any time by replying STOP or contacting clinic@modyfihealth.com. Your phone number will not be shared with third parties for marketing purposes. For full details, visit modyfihealth.com/privacy-practices.

Patient Rights & Responsibilities

Rights

• Be treated with dignity and respect.
• Actively participate in treatment planning.
• Receive services in the least restrictive setting.
• Have family involvement in care decisions, where appropriate.
• Maintain privacy and confidentiality.
• File grievances without retaliation.

Responsibilities

• Treat providers and staff with respect.
• Follow your treatment plan and attend scheduled appointments.
• Provide accurate and complete health information.
• Make timely payments for services rendered.
• Understand and adhere to your rights and responsibilities.

Discharge Policy

Patients who have not received services within 90 days and have not responded to outreach may be administratively discharged. A written warning will be issued with 30 days to respond or schedule an appointment. Patients discharged in good standing — defined as having no outstanding balance and no unresolved policy violations — are welcome to return to Modyfi care at any time.

Complaints & Grievances

• Informal complaints may be raised directly with your provider.
• Formal complaints may be submitted to info@modyfihealth.com or by mail to: 300 Delaware Ave., Suite 210, Wilmington, DE 19801.
• Urgent complaints involving safety concerns will be addressed within 48 business hours after receipt.

Modyfi Health • modyfihealth.com • 833-3-MODYFI • clinic@modyfihealth.com