Clinical Services Agreement

Effective Date: January 1, 2023

General Information

Brightline Medical Associates, P.A. and its affiliated entities, including, but not limited to Brightline Medical Associates of California, Inc., Brightline Medical Associates of Kansas, P.A., and Brightline Medical Associates of New Jersey, P.A., and their engaged clinicians (collectively, “BMA”) provide behavioral health services including psychiatry and medication support, psychology and behavioral therapy, and other behavioral health and developmental services. BMA also provides non-clinical coaching services from certified coaches through its affiliate, Brightline, Inc. (“Brightline”), our technology partner. Brightline is an administrative services entity and performs administrative, payment, and other business support activities for BMA and its clinicians. When you request to receive services for your child from a BMA clinician or Brightline coach (collectively, “Care Team”,“we”, “us”, or “our’) those services are outlined by this agreement, as well as the discussions between you, your child, and your clinician(s) or coach(es). It is important for you to read this document and discuss any questions you might have with your Care Team. If you agree to these terms we will assume that you have read, understood, and agree to its contents.

Our Services and Technology

When you become a Brightline member, you get access to the Brightline mobile or desktop application (“Brightline app”) and to a Brightline coach who works together with you, to provide the best possible care for your child. 

Brightline App and Brightline Connect+

The Brightline app provides personalized content and interactive resources for you and your family, simple tools for scheduling appointments and billing, serves as your hub of information including guided activities to do with your child, and connects you to your Brightline Coach or BMA Clinician, if you choose clinical care for your child.

Brightline Connect+ is our digital platform and foundation across all our offerings. Every single member will participate in Brightline Connect+ as a foundation, and as the main asynchronous connection to their Brightline Coach. Throughout your journey, your Care Team will keep you up-to-date on your child’s progress using the Brightline app. Before, throughout, and after treatment, you will have access to the Brightline app, which offers personalized content recommendations based on your expressed areas of interest, as collected through short assessments, chat or other modes of communication with a member of your Care Team, or your behaviors in the app indicating your viewing preferences. Information submitted during the course of completing interactive surveys or exercises in the Brightline app will not be actively monitored, but may be used to tailor recommendations for programs or for your care plan. If you need to contact your Brightline Coach or Member Support, they should be messaged directly.

Brightline Coaching

Your journey with Brightline starts with completing your onboarding through the Brightline app. You have already taken this step, and you will now move on to the next phase. You will be introduced to your coach, who can help answer questions related to skills introduced in the Brightline app. Depending on your needs, the first couple of sessions may involve further evaluation of your specific needs. Coaching sessions may occur through video conference, by phone, or through Brightline chat depending on the venue that works best for your child and your plan selection.

Coaching is a collaborative process with an ongoing relationship between you, your child and your Brightline Coach. The coaching experience supports you and your child in establishing new positive behaviors. The coaching relationship is strengths-based, forward-looking, and collaborative. The Coach agenda is developed in partnership with you to create a plan that includes shared goals and the role of your Coach is to help your child progress towards achieving those goals. 

Coaching is not therapy, counseling, or consulting and does not involve the diagnosis or treatment of mental health disorders as defined by the American Psychiatric Association. Your Brightline Coach receives specialized education, training, and takes a national exam in order to be qualified to be a coach at Brightline. You can learn more about your Brightline Coach’s background and area of speciality through the bio sent to your email. The Brightline content your Coach will share with you meets standards established by national credentialing organizations and is delivered to you under the supervision of a licensed professional.

Your Brightline Coach will be with you every step of the way and is available through chat in the Brightline app. You can reach out to your Brightline Coach at any time, and they will make every effort to respond during normal business hours. By entering into this relationship, both you and your Brightline Coach acknowledge a desire to make a behavioral change or some type of improvement in your child’s life. Behavioral change often takes time to implement and sustain. The pace of change is uncertain and varies among individuals.  

Our Brightline Coaches support you through your entire care journey. If the need for higher-level care is identified, or depending on your preference, you may continue to receive coaching services or get a clinical consultation with a licensed therapist. Your Brightline Coaches and BMA clinicians will share among themselves information you or your child have provided, and work collectively to support high quality and effective care for your family. 

Therapy with BMA Clinicians

The purpose of the clinical consultation is to understand your main concerns about your child and to determine if therapy services provided by BMA via telehealth is the appropriate next step. If it is determined that therapy is appropriate, you will be matched with a licensed clinician in your state who will talk with you and your child about your current situation, ask about personal history, and make recommendations for services. You will then develop a treatment plan together that outlines how treatment will proceed and what outcomes to expect. Therapy interventions at Brightline involve evidence-based approaches such as Cognitive Behavior Therapy (CBT), Dialectical Behavior Therapy (DBT) and Parent-Child Interaction Therapy (PCIT), to name a few. These approaches have been shown to be effective treatments for mental and behavioral health concerns.

Therapy is a dynamic, fluid process between therapist and member. There are many different therapy methods your therapist may use to address the issues of concern. Your therapist receives specialized education, training, and state licensure in order to be a qualified therapist at Brightline. You can learn more about your clinicians background and area of speciality through the bio sent to your email. 

BMA licensed therapists are not physicians and can not prescribe medication. Depending upon you and your child’s specific needs, your therapist may suggest additional services with other members of our team—specifically, our broader team of licensed physicians can provide medication, evaluation and support for treatment related to medical and biological origins. If you and your BMA therapist or physician believe that primary care services might be helpful, they can make a referral. If treatment needs fall outside the scope of practice for our BMA providers, we may refer you to your health plan or employer for in network referrals. BMA therapists and physicians will always discuss such recommendations with you. If you agree, our team will work together to provide you and your child with cohesive care and support. 

Medication Management

Brightline is a “therapy-first” approach. The decision to prescribe medication would be a shared decision making process between therapist(s) and member/family only after a therapy relationship is established.  If you request a medication consultation, your therapist will engage one of our nurse practitioners or physicians (psychiatrist, pediatrician) (each, a “Prescriber”) to meet with you, provide a medical evaluation, and discuss risk and benefits of medication management.  Once a child starts a prescription, Brightline will schedule regular meetings with you, your child, and your Prescriber to follow up and assess progress and response to medication. The frequency and timing of these meetings will depend on the Prescriber’s clinical judgment as well as standards of care and best practices. 

Once your child has achieved their treatment goals, your Care Team lead will work with you and your child to transition out of active care. At this point, you will no longer have regular therapy visits, but you will continue regular visits with your Prescriber if appropriate. You will continue to have access to the Brightline app and coaches and support from your Care Team for additional services if needed.

Session Procedure and Duration

Your personalized Coaching goal setting and/or therapy personalized care plans are derived from evidence-based treatments (EBTs) exclusively, including Cognitive Behavior Therapy (CBT), Dialectical Behavior Therapy (DBT), Parent-Child Interaction Therapy (PCIT), to name a few. These approaches focus on specific goals to promote symptom reduction as well as achieve greater emotional and behavioral balance. Treatment duration will vary based on severity and complexity of the challenges that members present with, but Brightline therapy is designed to be delivered as short-term, outpatient care. Clinicians consider if the member is an appropriate fit for Brightline therapy based on the severity and complexity of the members’ presenting concerns. For those who are a good fit for short term therapy, clinicians will inform parents/caregivers of the short-term framework (i.e., not intended for multi-year long therapy) and collaboratively develop a treatment plan with the family about what goals they will focus on and how they will go about achieving them.

Your personalized care plan will involve a series of sessions which may occur weekly or less than weekly.  The frequency of your sessions will likely decrease over time depending on your family’s needs. These appointments will be scheduled in advance. We will do our best to ensure a regular schedule, but times are subject to change depending upon your schedule and your Care Team Member’s availability.

Sometimes these sessions will be held with only your child, sometimes with only you, and sometimes you and your child together. For example, in therapy, we may ask for only your child to attend the first half of a session, and for you to join for the second half. Your Care Team will work with you to outline the schedule in advance and identify who needs to attend each session.

Our Coaching sessions are 30 minutes in length. Our Therapy consultations begin with an initial 60 minute intake appointment and subsequent sessions can vary between 30 minutes to 60 minutes in length depending on your care plan needs, the type of appointment, and the attendance of you, your child or both.

Attendance and Cancellations 

Beginning and finishing on time is an important part of ensuring progress and adherence to your child’s care plan. If you are ever running late, please let your Care Team member or Member Support know as soon as possible. If you arrive more than 10 minutes late for a scheduled appointment, your Care Team member will assume that the appointment is canceled and you will be responsible for the full payment amount of the appointment. If for any reason your Care Team member arrives more than 10 minutes late to an appointment, you may assume that the session is canceled and you will not be responsible for any payment for that session. 

We require a 24-hour advance notice for cancellations and re-schedules. If you cancel or reschedule an appointment within 24 hours of your appointment or do not show up for a scheduled appointment, you may be responsible for a portion or up to the full cost of the appointment. We know that things come up and you may have to reschedule or cancel an appointment from time to time. We will honor a one time courtesy during your course of treatment with us, to make a cancellation or reschedule within 24 hours with no obligation to pay the full amount. If we have to reschedule your appointment due to an unforeseen emergency on our end, your rescheduled appointment with us will be free of charge.

A late cancellation or no-show has an impact. A late cancellation or no-show means that we were unable to serve another person. If we have enough notice of a cancellation, we can provide help to someone else. Attendance and engagement is a key part of successful treatment. Canceling or missing more than 25% of your monthly sessions or three consecutive sessions, will be considered an attendance concern. If this happens, you will be asked to meet with your Brightline Coach or BMA Clinician to review the treatment plan and discuss if an alternative schedule will be more appropriate to help commit to a treatment plan. If attendance concerns continue, you could be asked to attend additional meetings or services may be terminated. If you have no-showed and have not scheduled an appointment after 30 days, we will assume you are ending your treatment. We may close your file at that time. You may contact us to schedule an appointment to become active again.

Parent Authorization for Child’s Behavioral Health Services  

In order to authorize mental health treatment for your child, you must be the child’s legal guardian. If divorced or separated, you must have either sole or joint legal custody of your child and be authorized to grant permission for medical treatment to include psychiatry, medication support, psychology, behavioral therapy, and other behavioral health developmental services. This means that you are not a party to or otherwise the subject of any agreement or court order that requires written approval of the child’s other parent or any third party to authorize behavioral health services for your child. If you are a party to such an agreement, you have obtained all necessary written approvals and all parties support your child’s use of Brightline services. By consenting to Brightline services, you attest that you have the authority to make medical decisions on behalf of the child being treated and that all parties who have legal custody of the child have been made aware of, and consent to the minor’s treatment.

If you are separated or divorced (or become separated or divorced) from the other parent of your child, you agree to immediately notify the other parent that Brightline or BMA is meeting with your child. BMA believes it is important that all parents have the right to know, unless there are truly exceptional circumstances, that their child is receiving behavioral health services.  You also agree to provide, if we make a request, a copy of the most recent custody decree that establishes the custody rights of you and the other parent, or otherwise demonstrates that you have the right to authorize treatment for your child.  If there are any changes in the status of legal guardianship/parent status, you understand that it is your responsibility to promptly notify BMA of any such changes.  

One risk of child therapy involves disagreement among parents and/or disagreement between parents and the child’s BMA clinician regarding the child’s treatment. If such disagreements occur, we will strive to listen carefully so that we can understand your perspectives and fully explain our perspective.   If either parent decides that behavioral health services should end, BMA will honor that decision, unless there are extraordinary circumstances. However, in most cases, we will ask that you allow us the option of having a few closing sessions with your child to appropriately end the relationship. 

During the treatment of your child, BMA may meet with the child’s parents/guardians either separately or together. Treatment is about the child (or children) not the parents/guardians or other family members of the child. BMA will work with parents/guardians to offer support services about helping that child meet their goals and resolve concerns. Furthermore, any communication by a parent may be legally disclosed to the other parent. A parent should NOT share any information which they are not willing to have disclosed to the other parent.  

Informed Consent

Telehealth

Telehealth involves the use of two-way audio, video-conferencing technology, or other electronic communication to enable your BMA Clinician or Brightline Coach to interact with you and provide coaching sessions, clinical consultation, or treatment from a remote location.  The flexibility of telehealth allows for a greater degree of convenience for you, but it also has some limitations. Below are some rules and guidelines that we require our members to follow so we can provide your child with the best care. These guidelines include, but are not limited to:

• A quiet and private location for video calls
• A fast and clear internet connection that is both private and secure
• A sensitive microphone that enables you to be able to speak and hear well
• A video camera that is positioned so that we can see you and/or your child
• We also require that you or your child’s parent/legal guardian be available and regularly involved in your child’s sessions and treatment plan based on our model of care. If a session is with your child only and you will not be in attendance, please ensure that you inform your child’s clinician in advance and provide your phone number so that you are available at all times in case of emergency. 
• That you and your child are located in the state where you maintain legal residence and where your BMA clinician is licensed to practice. 

The electronic communication systems we use for services delivered via telehealth will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption. All the services delivered to you through telehealth will be delivered over a secure connection that complies with the requirements of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). Notwithstanding these security measures, in very rare events, security protocols could fail, causing a breach of privacy of protected health information.

Telehealth/telemedicine sessions may not always be possible. Disruptions of signals or problems with the Internet’s infrastructure may cause broadcast and reception problems (e.g., poor picture or sound quality, dropped connections, audio interference) that prevent effective interaction between the consulting provider, participant, or member.

In addition, it is important to note that telehealth may not be appropriate for the treatment of certain symptoms or diagnoses that would benefit from the availability of an in-person appointment. There are some behaviors, such as an inability to follow your child’s care plan, which may cause your BMA clinician(s) to refer your case elsewhere. Your clinician(s) will make every effort to discuss these concerns with you, but your clinician(s) reserve the sole discretion to discontinue treatment via telehealth if necessary.

By signing this agreement, you acknowledge your understanding of the risks and benefits of telehealth services and that you have the opportunity to ask your Brightline Coach or BMA Clinician any questions prior to receiving the services including any alternatives to care as described above. 

Video Recordings

With your permission, in certain cases, your child’s Care Team member may record sessions for quality reviews, operations, training, research and safety purposes. We may also request that you provide videos of your child to assist in your child’s care and treatment. Those videos will be used internally by the Care Team for treatment and care coordination purposes.

Mental Health Treatment

Mental health services are generally effective in treating most mental health conditions. We will monitor progress and outcomes to ensure your child is benefiting from our care. Few people get worse from treatment. Improvement requires attending appointments and following through with treatment recommendations. There may be challenges associated with Coaching and/or Therapy. These include uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, anxiety, and helplessness. Your child is encouraged to discuss these challenges with your Care Team member at any time. We cannot guarantee specific results of treatment. The benefit of treatment can lead to better relationships, solutions to specific problems, and significant reductions in feelings of distress.

You should evaluate this information along with your own opinions of whether you feel comfortable moving forward. Treatment involves a large commitment of time, money, and energy, so please consider this carefully before making this decision. If you have questions about any of these procedures, it is very important that you raise all of your questions whenever they arise. Your Care Team will not be offended or upset if you raise concerns. Rather, your Care Team will welcome questions and are trained to discuss your concerns with you. You have the right to ask for a referral to another provider or to terminate care at any time. If you would like to terminate for any reason, your Care Team will support you in your decision. 

We also want to make clear that mental health treatment is a constantly changing process. Though this Clinical Services Agreement outlines some of our requirements, procedures, and policies, symptoms and circumstances may change. We reserve the right, and you should expect, that if symptoms of circumstances change in such a way that your Care Team no longer believes that care with BMA is advisable, your treatment may be concluded or referred elsewhere. This is particularly important when it comes to services provided via telehealth, as discussed above.

Treatment Options and Medical Necessity 

Some health insurance companies will reimburse for non-clinical services such as coaching and/or counseling services, and some will not. In some cases, your use of our services must meet the definition of “medical necessity.” Your health plan outlines which conditions are covered and which are limited or excluded. Most mental health conditions are covered by most plans.  If a qualifying diagnosis is appropriate in your case, it may be submitted to your health plan. Any diagnosis made will become part of your permanent insurance records. 

EMERGENCIES

BMA clinician(s) are not available to address 24/7 crisis response.  In case of an emergency outside of normal business hours, please contact 9-1-1 and/or go to the nearest emergency room. An emergency means a situation where your child is in immediate danger of harming themselves or others. If your child is in distress and needs to talk to someone right away, call or text 988 (Suicide & Crisis Lifeline). You can also chat from a computer at 988 lifeline.org. 

For non urgent behavioral healthcare, please contact Member Support or schedule an appointment through the Brightline app. 

Nondiscrimination

Brightline and BMA do not discriminate against any member with respect to the delivery or accessibility of services on the basis of race, ethnicity, national origin, religion, sex, age, disability, sexual orientation, the type of health insurance, claims experience, medical history, genetic information, or type of payment.

Financial Responsibility and Assignment of Benefits 

Payment and Billing

Our services and pricing are provided under two payment structures:

1. Per-session fees for coaching and therapy services that are based on your child’s treatment.
2. Membership fees for premium services and resources available in our member app. Members will be informed before purchase of any membership fees associated with accessing premium resources.

For self-pay members, you are responsible for all payments. All billing is done using a credit card that you provide to us when you create your account. You can update your credit card on file at any time in the Brightline app or by speaking with member support. If your credit card is declined, we will follow up with you directly to update your credit card on file. Please note that if you have an unpaid balance, services may be interrupted or terminated.

For members who are employed by companies that Brightline and BMA partner with, your services may be covered under the terms of Brightline and BMA’s contracted benefits for your employer. For members who have insurance with health plans where BMA is in-network, your services may be covered by your insurance. You have options. Other network providers may offer telehealth and in-office visits. If you see an out-of-network provider, the terms of your plan apply whether you visit in person or virtually. If you have any questions about your eligibility under insurance through your employer, please reach out to your Care Team.

Acknowledgement of Responsibility

BMA has agreed to accept assignment of benefits from certain Payors (e.g., such as certain insurance providers). You will remain personally responsible for payment in full for billed charges to those Payors, unless otherwise required by law. You are responsible to pay all copays, deductibles, co-insurance, and/or other charges, such as services that are not covered by your Payor. By signing this agreement, you agree to pay amounts you owe to BMA in accordance with our payment policies.

By signing this agreement, you also acknowledge that you have had the opportunity to obtain answers to any questions regarding your financial responsibility, and understand and agree with the terms mentioned in this section. If you have any remaining questions about your financial responsibility, it is important that you discuss these questions/concerns with the Brightline Member Support team.

Your endorsement and agreement of this Clinical Services Agreement constitutes your understanding that Brightline uses a credit card processing company to process payments. Your submission of your credit card information to Brightline, in conjunction with your agreement of this Clinical Services Agreement, authorizes Brightline to charge the credit card on file for agreed-upon purchases. You understand that your credit card information will be saved on file for future transactions on your account.

Assignment of Benefits for Insurance/Health Plan

If you qualify for benefits from any insurance company(ies) or health plan(s), by signing this form, you are agreeing to the following:

• Assigning those benefits to BMA to pay for care provided
• Signing any additional forms required by any insurance company or health plan (each a “Payor”) to confirm this assignment of benefits.
• Authorizing BMA to release all relevant information about your child and their health care necessary to receive payment from the applicable Payor and signing an authorization permitting such release to the extent requested by BMA.

Right to Revoke Authorization

You have the right to revoke your authorization at any time for BMA or Brightline to release information about your child and their health to any Payor. We ask that you submit the revocation request via email to care@hellobrightline.com. It will be effective upon our receipt of your email.

Confidentiality

In general, the privacy of all communications between a clinician or coach and member is protected by law, and your clinician(s) and coach(es) can only release information about your child’s treatment to others with your written permission or as otherwise permitted by law. If you do not want us to share information about the care you receive with your primary care provider, let your care Care Team Member or Member Support services know you would like to opt out to the sharing of this information. For more information, see our Notice of Privacy Practices.

In cases where the Care Team is asked to work collaboratively with a family’s external stakeholders, such as a child’s pediatrician or school, we use the Release of Information form to seek written permission to exchange information with external stakeholders.  Further, in cases where a child exhibits signs of emotional disturbance, as defined under Sec 300.8(c)(4) of the Individuals with Disabilities Education Act, we are required to inform the child’s school as required under federal law.

U.S. Children’s Online Privacy Protection Act (“COPPA”)

As part of the services, we will collect the personal information of your child. Your consent is required for the collection, use, and disclosure of your child’s information and we have collected your information in order to obtain this consent. We will not collect your child’s personal information unless you consent. However, if you do not give your consent, your child may not use our services.

The types of personal information we collect directly from a child include:

• any information the child provides to us during an appointment, including health related information, or while logged into the account you created if you provide the child with your credentials (we do not allow children under age 18 to register directly for an account at this time);
• information about the child’s use of the services, including information sent by the mobile device or computer used by the child (e.g., IP address, unique device identifiers, website usage information, etc.) and information sent by the mobile device(s); and
• location information.

We use and disclose that information:

• to provide the services;
• for the operation and administration of our business, including disclosures to our business clients who purchase our services for their employees and dependents;
• for business analytics purposes;
• for our own marketing purposes;
• to provide customer support to you;
• for account and network security purposes;
• to maintain legal and regulatory compliance; 
• to enforce compliance with our agreements and policies; and
• as described and permitted in our Privacy Policy.

Your agreement, below, constitutes your consent to the collection, use, and disclosure of your child’s information, as described in this Clinical Services Agreement and the Brightline Privacy Policy. A parent or guardian may revoke this consent at any time. However, once consent is revoked, a child may not use our online services again unless a new Clinical Services Agreement is signed. If you do not provide your consent within a reasonable period of time, we will delete your information from our records.

Complaint Policy

You have the right to communicate grievances regarding your care or the care of your child.  Should you wish to make a formal complaint about one of your child’s care Care Team Members, you may do so in writing and submit the concern to us at care@hellobrightline.com.

For California-based members

NOTICE TO CLIENTS: The Board of Behavioral Sciences receives and responds to complaints regarding services provided within the scope of practice of (marriage and family therapists, licensed educational psychologists, clinical social workers, or professional clinical counselors). You may contact the board online at www.bbs.ca.gov, or by calling (916) 574-7830.

Agreement and Consent

If you have questions about any of the contents of this Clinical Services Agreement, our procedures, or your role in this process, please discuss them with your Care Team. Remember that the best way to ensure quality treatment is to keep communication open and direct with your clinician.