Telehealth Consent

(NH & MA)

Purpose: This section is an informed consent for receiving psychiatric treatment via telehealth. Telehealth (or telemedicine) means that you will receive care from our psychiatric nurse practitioner/s using electronic communications (such as live two-way video conferencing), rather than meeting in-person for all appointments. We provide telehealth services to patients located in New Hampshire and Massachusetts in accordance with applicable laws and professional standards. Before beginning telehealth services, it is important you understand the benefits, risks, and your rights regarding telehealth.

Nature of Telehealth: Telehealth involves the use of secure realtime video (and/or audio) communication to enable you and the clinician to see and speak with each other from different locations. At OffBenzos.com, operated by Six States Wellness Pllc, we use a HIPAA-compliant Zoom for Healthcare platform integrated through our EHR for all virtual visits. You will be able to attend appointments from a private location of your choice (e.g., your home or office) using a computer or smartphone with camera and microphone. The experience is similar to an in-person session in most ways, except that you and the provider will not be in the same room.

Telehealth Eligibility: You must physically be located in the state of New Hampshire or Massachusetts at the time of the telehealth session, because our provider is licensed only in those states. We will ask you to confirm your current location at the start of each session. If you are traveling or relocate outside of these states, please inform us as this may affect our ability to continue telehealth services or prescribe certain medications across state lines. In such cases, we will discuss alternatives (such as temporary arrangements or referrals).

Potential Benefits of Telehealth

• Improved Access: Telehealth allows you to receive care without the need to travel to our office. This can be especially beneficial if you live far away, have transportation challenges, or have a busy schedule. It expands access to specialized care throughout NH and MA.
  
  

• Convenience and Continuity: You can attend sessions from the comfort of your home. Follow-up appointments may be easier to fit into your day, which helps ensure you stay consistent with treatment. Telehealth can facilitate more frequent check-ins if needed, contributing to continuity of care.
  
  

• Flexibility: In circumstances such as bad weather, minor illness, or pandemics, telehealth enables care to continue uninterrupted. It also can accommodate patients who might otherwise miss appointments due to work or family obligations.
  
  

• Patient Comfort: Some individuals feel more at ease speaking about personal issues from their own familiar environment. This comfort can sometimes make it easier to engage in therapy or consultations.
  
  

• Reduced Wait and Efficiency: Without commute times, often appointments can start promptly. You also avoid sitting in a waiting room. In some cases, it may be easier to loop in family members or other participants if needed (with your permission) via teleconference.
  
  

Potential Risks and Limitations of Telehealth

While we believe telehealth is a safe and effective way to provide psychiatric services, it does have some limitations and risks to consider:

• Technology Problems: The quality of the video connection might be affected by internet bandwidth or technical issues. You might experience poor video/audio quality, delays, disconnects, or equipment failures. This could lead to misunderstandings or the need to reschedule or switch to a phone call. We will do our best to troubleshoot issues, but there is a chance a telehealth session could be disrupted or less effective due to technical difficulties.
  
  

• Privacy Concerns: We use a secure platform to protect your privacy; however, privacy on your end depends on your environment. There is a small risk that someone could overhear or see your telehealth session if you are not in a private location. We recommend you choose a quiet, private place for your session and use your own secure internet connection (avoid public Wi-Fi). Additionally, while unlikely, any internet communication could theoretically be intercepted. Our platform’s encryption makes this risk very low, but not absolutely zero. We have taken steps to mitigate this risk in compliance with law.
  
  

• Lack of Physical Presence: In a telehealth visit, the provider cannot perform certain types of exams (for example, checking your blood pressure, doing a physical neurological exam, etc.). We rely on your verbal information and observable cues on video. This limitation means there is a risk something could be missed that might be noted in person (such as subtle physical signs). We mitigate this by requesting you have regular in-person physical exams with a primary care provider, especially if you are on medications that require monitoring (e.g., blood pressure checks for stimulant medication). If during a telehealth session, it becomes apparent that an in-person evaluation or intervention is necessary, the provider will discuss this with you and may recommend an in-person visit or refer you appropriately.
  
  

• Incomplete Data or Miscommunication: Without being in the same room, it might be slightly harder to read certain non-verbal cues or to ensure mutual understanding. There’s a potential for miscommunication or misunderstanding instructions. We will take extra care to speak clearly and confirm your understanding of important points. You are encouraged to ask questions if anything is unclear.
  
  

• Emergency Situations: In the unlikely event that you have an urgent medical or psychiatric issue during a telehealth session (e.g., you faint, or you experience a severe psychological crisis), the provider cannot be there in person to assist. We will have an emergency plan (see below) to handle such situations, but response may be inherently less immediate than if you were on-site.
  
  

• Variability in Effectiveness: Telehealth is effective for many psychiatric services, but it may not be appropriate for all situations or all patients. For example, certain complex assessments or severe psychiatric conditions might require in-person evaluation. If we determine telehealth is not the best option for your particular situation, we will discuss alternative arrangements (such as in-person visits or referral to a provider who can see you in person).
  
  

Patient Rights and Responsibilities in Telehealth

Your Rights: When receiving telehealth services from us, you maintain several important rights:

• Right to Refuse Telehealth: You have the right to decline receiving services via telehealth at any time. Telehealth is voluntary. If you do not want to use telehealth, or if you want to stop telehealth and resume in-person care (or end treatment), you are free to do so. Your decision will not affect your right to future care, though we may need to discuss alternatives (for instance, if you cannot come to our office and do not want telehealth, we might refer you to a closer provider). Be aware that refusing telehealth might mean delaying or not receiving certain services if in-person is not available, but that choice remains yours.
  
  

• Identification of Provider and Credentials: You have the right to know the identity and credentials of the healthcare provider on the video session. Our telehealth visits will be with a licensed Psychiatric Mental Health Nurse Practitioner (PMHNP) in either NH or MA. We will introduce ourselves and confirm our location (city and state) at the start of the session, so you know where we are practicing from. Typically, our provider will be in a private office or similar setting in one of those states.
  
  

• Equality of Care: You have the right to receive care via telehealth that meets the same standard as in-person care. Telehealth services provided will conform to the standard of care for our profession just as if this were an in-person appointment. We will devote our full attention during the appointment and ensure you have time to ask questions, just like during an office visit.
  
  

• Privacy and Confidentiality: Your rights to privacy extend to telehealth. Sessions are private and not observed by anyone on our side who isn’t disclosed to you. You have the right to be informed of all persons present at our end during the telehealth encounter (e.g., if a nurse or trainee were present, though in our case we generally do not have others present without asking you). We will also confirm that no one else is listening in on the call on our side. If you ever suspect an unwanted intrusion, please inform us immediately. You likewise have the right to privacy on your end; if you want a family member present or to sit in, that is your choice, and we ask you inform us who else is in the room on your side.
  
  

• Language and Communication: If you have language preferences or hearing/vision needs, you have the right to request accommodations. We will provide culturally and linguistically appropriate services, including interpretation if you are not fluent in English (with advance notice, we can arrange a medical interpreter or accommodate ASL interpretation). Let us know if you require translation services or any aid to communicate comfortably.
  
  

• Emergency Care: You have the right to be referred to in-person care (including emergency services) when needed. If during a telehealth session a situation arises that requires immediate in-person assessment (for example, a severe reaction or suicidal crisis), the provider will advise and assist in getting you appropriate emergency help (such as calling 911 or directing you to the nearest hospital). We will never simply disconnect if you are in crisis; we will engage emergency protocols as needed. (See Emergency Plan below.)
  
  

• Option for In-Person Visits: Where feasible, you have the option to request an in-person appointment instead of telehealth. Our practice offers both in-person and telehealth services (subject to scheduling and location availability). If you prefer an office visit for any reason (or for certain types of appointments), please let us know and we will accommodate if possible. In some cases (such as exclusively virtual clinics or if distance is too great), in-person might not be practical, in which case we can discuss referral or other arrangements.
  
  

• Right to Withdraw Consent: Even after consenting to telehealth, you retain the right to change your mind. You can withdraw your consent to telehealth either verbally during a session or by informing us in writing (e.g., email) at any time. There is no penalty for withdrawing consent. We will then discuss alternative plans for continuing your care, which may involve scheduling in-person visits if you are able to come to our office, or assisting you in finding local services if you are no longer within our reach in-person. (Do note that if you withdraw consent for telehealth and cannot do in-person, it might necessitate discontinuing services with us and referral to another provider.) Your health and preferences will guide our next steps.
  
  

Your Responsibilities: To ensure that telehealth sessions are effective and secure, patients have certain responsibilities as well:

• Equipment and Environment: You are responsible for having the necessary equipment (smartphone, tablet, or computer with camera and microphone) and a reliable internet connection for sessions. Test your device before the appointment if possible. Try to be in a quiet, private location with minimal disruptions. Use a secure network and, if others are around, consider using headphones and sitting where your screen isn’t visible to others. This will help maintain your confidentiality.
  
  

• Timeliness: Please log in to the telehealth session a few minutes before the scheduled time. If you encounter issues logging on, notify us as soon as possible. If you will be late or need to reschedule, treat it as you would an in-person appointment and inform us. Our standard policies on no-shows or late cancellations apply equally to telehealth visits.
  
  

• Providing Accurate Information: During telehealth sessions, please communicate as clearly and thoroughly as you can about your symptoms, medication effects, or any changes in your health. Because we cannot measure things like blood pressure or weight in person, we might ask you to provide recent vital signs from another provider or self-report if you have home devices. We rely on you to report truthfully and accurately to the best of your ability.
  
  

• Safety Planning: You must inform the provider of your current physical address at the start of each telehealth session. This is so that in the event of an emergency, we can dispatch help to the correct location. Also, please provide a phone number and an emergency contact person we can reach if needed (in case of technical failure or crisis). If your location changes mid-session (for example, you leave home), let us know. Keeping your contact and emergency information updated is your responsibility.
  
  

• Follow-Up Care: Understand that telehealth is just one mode of care. You agree to follow our recommendations for follow-up, whether that means scheduling your next telehealth visit or obtaining lab tests or seeing your primary care doctor in person for complementary care. If we advise that you seek urgent or emergency in-person care (for example, go to an ER), you agree to take that advice seriously for your own safety.
  
  

• Technology Familiarity: You don’t have to be a tech expert, but try to familiarize yourself with the basic use of the telehealth platform. We will send instructions for connecting to Zoom. If you need help, ask ahead of time. By starting the telehealth, you are acknowledging that you are comfortable proceeding in this format. If you struggle with the technology, we can explore alternatives (like a regular phone call, although purely telephone sessions have more limitations and may not be covered by insurance in some cases).
  
  

Confidentiality in Telehealth

We have explained in our Privacy Policy how we protect your information. Here we reiterate key privacy measures specifically for telehealth:

• The session is conducted on Zoom for Healthcare which is encrypted and HIPAA-compliant. Only you and the provider (and any explicitly invited participants) are in the virtual meeting room.
  
  

• We will not record the session without your permission, as stated. We also request that you do not record the session without informing us. If you wish to record for personal use, you must discuss this with the provider and obtain consent.
  
  

• All rules of confidentiality that apply to in-person medical services apply to telehealth. We will document the session in your medical record just as we would an office visit. That record is protected by our usual privacy safeguards.
  
  

• If you are using the patient portal or email to send any information before/after the session, use the secure portal whenever possible for PHI. Standard email or text messages are not fully secure. If you choose to communicate via standard email or text for convenience, we may ask you to acknowledge the privacy risk.
  
  

• Be mindful of your own environment: having someone unexpectedly walk in or hearing what you say could compromise your confidentiality. You have the right to pause or request to reschedule if your privacy cannot be ensured at your location.
  
  

Emergency Plan for Telehealth

We take your safety seriously. Before beginning telehealth services, we will establish an emergency plan with you. This includes:

• Your Location and Emergency Contact: As noted, at each telehealth session we will verify your physical address and have on file an emergency contact (someone we can reach, such as a family member or friend, in case an emergency arises). By proceeding with telehealth, you agree to provide this information and permit us to contact emergency services or that person if we deem it necessary for your safety.
  
  

• If a Crisis Occurs During a Session: For example, if you experience a severe panic attack, express suicidal intent, or have a medical collapse during the call, the provider may attempt to keep you on the video while simultaneously contacting local emergency responders to send help to your location. If you disconnect and we are concerned for your safety, we will use the information we have to call 911 on your behalf and/or contact your emergency contact. We will do our best to notify you of this action and the reasons for it.
  
  

• If Technology Fails: If the video call drops and we cannot reconnect, we will attempt to reach you via phone. Please ensure we have a correct phone number. If we cannot reach you and we have concern for your wellbeing (for instance, you were in the middle of discussing something critical), we may reach out to your emergency contact or call emergency services to do a wellness check. If there were no known safety concerns at that moment, we will simply wait for you to reconnect or contact you to reschedule.
  
  

• After-Hours Emergencies: Telehealth is not designed for emergency care. If you are between sessions and experience a psychiatric emergency (for example, you have thoughts of harming yourself or others that you feel you might act on), do not wait for a telehealth appointment. Instead, call 911 or go to the nearest emergency room for immediate help. You can also call crisis hotlines such as 988 (the Suicide & Crisis Lifeline in the U.S.). Once you are safe, you or the hospital can notify us of what occurred. We will also provide guidance on who to contact (e.g., local crisis lines) as part of your safety planning.
  
  

• Local Backup Plan: If you know that you live far from emergency services (e.g., rural area) or have particular medical conditions, we might ask if there’s someone near you who can be on standby during high-risk discussions or if we should schedule telehealth at times when another support person is present at your home (only if you’re comfortable) as an extra precaution.
  
  

By signing this Telehealth Consent (or otherwise agreeing to telehealth services), you acknowledge that you understand the above emergency plan and your role in it (providing accurate info, following emergency instructions, etc.).

Billing and Insurance for Telehealth

Telehealth services at our practice are billed similarly to in-person services. In both Massachusetts and New Hampshire, telehealth parity laws generally require insurance to cover telehealth for behavioral health as they would in-person visits. You are responsible for any copayments, coinsurance, or deductibles as determined by your insurer, just as with office visits. We recommend confirming with your insurance that tele-mental health sessions are covered. If you are private pay, our session fees for telehealth are the same as in-person.

If your insurance for some reason does not cover a telehealth session (for example, if you had a policy that opted out of telehealth coverage), you would be responsible for the session fee. We will help inform you of any coverage issues we are aware of. Additionally, if an in-person service (like a certain procedure) cannot be done via telehealth, we will let you know and possibly have you come in-person or schedule that service elsewhere.

There is no charge for the telehealth technology usage itself on your end (the Zoom link we provide is free for you to use; any cost is part of our practice overhead). However, you are responsible for any internet or data charges from your own provider for connecting.

Consent to Telehealth Services

By agreeing to engage in telehealth appointments with Six States Wellness PLLC, operating the website Offbenzos.com, you confirm that:

• You have been informed about how telehealth works, its potential benefits, and limitations. All your questions have been addressed to your satisfaction.
  
  

• You understand that you have the right to refuse or discontinue telehealth services at any time without losing your right to future care or facing penalty.
  
  

• You agree to the conditions and patient responsibilities outlined above (regarding technology, privacy, emergency planning, etc.).
  
  

• You authorize the transmission of your information electronically for the purpose of your treatment, and consent to our documentation of telehealth sessions in your medical record.
  
  

• You understand that no guarantees have been made about the results of treatment via telehealth; however, you understand the provider will follow standards of care.
  
  

• If you have any concerns about telehealth, you will voice them with your provider to seek solutions or alternatives.
  
  

Typically, we will ask you to sign a separate Telehealth Informed Consent form (electronically or on paper) prior to your first telehealth appointment. This webpage copy serves as the detailed information about that consent. If you agree to these terms and proceed with scheduling a telehealth visit, it indicates your consent.

Please retain a copy of this Telehealth Consent information for your records. We are happy to provide you a printed or electronic copy on request.

AI Scribe Consent (Use of JotPsych by SmartScribe)

Purpose: Six States Wellness Pllc, operator of OffBenzos.com, aims to provide you with attentive and personalized care. In order to help our clinician focus on you during sessions (instead of busy note-taking), we utilize an AI-powered scribe technology called JotPsych (developed by SmartScribe Corp.) to assist in creating clinical documentation. This section explains what JotPsych is, how it will be used in your care, what data it handles, and to obtain your consent for its use during your sessions. Your participation is voluntary, and you may opt out if you have concerns.

What is JotPsych?

JotPsych by SmartScribe is a secure technology tool that listens to the conversation during medical appointments and generates draft clinical notes from that dialogue. Think of it as a highly advanced note-taking assistant. It uses speech-to-text and artificial intelligence to summarize the important details of our conversation (such as symptoms you describe, medications discussed, treatment plans, etc.). The primary goal of JotPsych is to allow the provider to give you full attention without constantly typing, while still producing accurate and timely documentation of the visit. This can improve the quality of our interaction, as the provider can maintain better eye contact and listen more actively, knowing that note details are being captured in the background.

JotPsych runs on a secure device/application that will be present (typically a smartphone or computer in the office) which picks up the “ambient conversation” in the room (or over telehealth) and transcribes it in real time. The provider will later review the AI-generated note for accuracy, edit it as needed, and then save it to your official medical record. JotPsych may also assist by highlighting key points or suggesting sections for the note, which the clinician verifies.

How Your Data Will Be Used with JotPsych

If you consent to the use of JotPsych during your sessions, here is how the information is handled and used:

• Documentation of the Visit: The audio of our conversation is processed by the JotPsych system to create a text draft of the clinical note. Important details like your symptoms, concerns, diagnosis, and treatment plan are transcribed. This draft is then used by the provider to complete the official visit documentation. The resulting note (after the provider’s review) becomes part of your medical record, just as a typed note would. The AI’s role is supportive; the provider remains responsible for the content and accuracy of your chart. No final documentation goes into your record without clinician approval.
  
  

• Quality Improvement and Training: The data captured may be utilized by SmartScribe Corp (the company behind JotPsych) to improve their service. This could include quality assurance processes such as algorithm training or accuracy checks. Importantly, any use of data for these purposes is done in compliance with privacy laws – typically data is aggregated or de-identified when used to improve the AI, meaning they are not focusing on your individual identity, but rather patterns across many conversations to refine the technology. Our clinic may also review how the AI is performing as part of quality improvement for our documentation workflow, but again your privacy is maintained.
  
  

• Compliance with Privacy Laws: SmartScribe Corp. and our practice will comply with all applicable federal, state, and local laws regarding the privacy and security of your information, including HIPAA. This means the audio and transcripts are protected with encryption and treated as Protected Health Information. SmartScribe acts as a Business Associate to our practice, bound by a contract to protect your data. The information from the AI is not made public or shared outside of the purposes stated (documentation and quality improvement) unless required by law or you authorize it.
  
  

• Storage of Audio/Text: You might wonder, does the system keep a recording of our session? According to SmartScribe, they handle data with utmost care. Typically, the audio is processed in real-time to text. The text draft is saved for the provider to review. SmartScribe’s policies (see below) indicate that data is stored securely. We will treat the transcript as part of your medical record under HIPAA. We do not separately keep audio recordings of sessions beyond what the AI uses in the moment (unless a recording is specifically made for some reason, which is not our standard practice). Any data stored by SmartScribe is safeguarded and only accessible to authorized persons (like your provider or the SmartScribe system for processing).
  
  

What JotPsych/SmartScribe Will NOT Do

• No Guarantee of Outcomes: While JotPsych aims to improve documentation efficiency, SmartScribe Corp. does not guarantee that using this technology will improve medical outcomes or lead to faster diagnosis or any specific benefit to you. In other words, it’s a tool for note-taking convenience; your care quality will continue to depend on the clinician’s expertise and your collaboration. You should not expect, for example, that the AI will catch something the provider might miss or that it adds any diagnostic capability. It is not a decision-making AI, it’s a documentation aid.
  
  

• No Decision Making or Advice: JotPsych will not be giving medical advice, making decisions, or speaking to you. You might not even notice it during sessions beyond perhaps seeing a device that’s enabled for it. All treatment decisions will still be made by your human provider. The AI does not replace any part of the therapeutic interaction; it operates in the background.
  
  

• No External Use of Raw Data: SmartScribe will not sell your personal data or use it for advertising. They will not contact you directly. The content of your sessions is not used outside of the context of providing this service, except potentially in an anonymized way for improving the algorithm as mentioned. Also, our clinic will not use the AI transcripts for anything other than your care documentation and internal quality checks. For example, we won’t be publishing your conversations or using them in case studies without your explicit consent and de-identification.
  
  

Data Privacy and Security with JotPsych

SmartScribe Corp. states that it takes privacy and security of your information very seriously. Here are key privacy points:

• HIPAA Compliance: JotPsych and SmartScribe are designed to be HIPAA-compliant. This means they implement administrative, physical, and technical safeguards required by law to protect health information. Data transfer between our devices and SmartScribe’s servers is encrypted. Access to their system is restricted to authorized users. They also likely have audit controls and monitoring to prevent and detect any unauthorized access.
  
  

• Independent Verification: SmartScribe works with independent third parties to verify their compliance and security (according to their statements). This should give additional assurance that an outside entity has evaluated their system’s security measures.
  
  

• Your Ability to Review Policies: SmartScribe has their own Terms of Service and Privacy Policy which you have the right to review. They are available online at:
  
  

• SmartScribe (JotPsych) Terms of Service: https://www.jotpsych.com/terms-of-use:contentReference[oaicite:46]{index=46}
  
  

• SmartScribe (JotPsych) Privacy Policy: https://www.jotpsych.com/privacy-policy:contentReference[oaicite:47]{index=47}
  
  

• These documents provide detailed information on how SmartScribe uses data, legal rights, and protections. We encourage you to read them if you have concerns. If you have trouble accessing them, we can provide a copy.
  
  

• No Unauthorized Access: The raw audio or interim transcript is not accessible to anyone except through the secure SmartScribe system. Within our practice, only the clinician (and perhaps designated technical staff for support) would have access to the transcripts. We treat the transcripts with the same confidentiality as therapy notes. SmartScribe’s staff (engineers or data scientists) might see snippets if debugging or improving the AI, but they are bound by confidentiality agreements and the data would typically be de-identified.
  
  

• Data Retention: The final notes become part of your chart indefinitely (per medical record retention laws). As for the audio or draft data on SmartScribe’s side, they may retain transcripts for a certain period for quality purposes. If you ever revoke consent (see below), we will ensure no further data from future sessions is sent to SmartScribe. Data already processed would still likely reside in past records.
  
  

Your Choice and Rights

Using the AI scribe is completely optional. We believe it enhances our note-taking process, but your comfort is our priority. Here are your rights regarding JotPsych:

• Right to Refuse or Opt-Out: You do not have to consent to the use of JotPsych. If you decline, we will simply take notes manually as we traditionally would. This might mean the clinician types more during sessions or scribbles notes on paper. You may notice slightly more pauses as we document, but we will ensure your care is not compromised. There is no penalty or loss of benefits if you refuse the AI scribe; you will receive the same quality of care. If you initially consent and later change your mind, you can withdraw consent at any time. Just inform us (preferably in writing, so we have a record). We will then stop using the AI for your sessions moving forward, with no questions asked.
  
  

• Right to Ask Questions: Feel free to inquire how the system works or request that we show you the device set-up. We can explain how we activate it and how the data flows. Transparency is important; you have the right to know what’s happening with your information.
  
  

• Right to Access Documentation: You always have the right to see the notes in your medical record (as described in the Privacy Policy section). The presence of AI doesn’t change that. If you want to know what note was generated or how it looks, you can request a copy of your visit note through the patient portal or medical records request. You’ll see the finalized note (which is based on the AI draft, edited by the provider). If you have concerns about accuracy, bring them up.
  
  

• No Recording Beyond Note: We reiterate that no one is creating a saved audio or video recording of your session for other purposes when using JotPsych. It’s distinct from, say, recording a Zoom meeting. The AI might temporarily buffer audio to process it, but it’s not keeping an accessible recording that could be replayed. If you still feel uneasy or if you have a very sensitive discussion and want the AI off for that portion, you can say so. For instance, you might consent but say “please pause it while I discuss this one thing.” The provider can mute or deactivate the capture if needed. We want you to be comfortable being candid.
  
  

• Quality Control: By consenting, you understand that SmartScribe’s team might review de-identified snippets for quality control. If you had any objection to even de-identified use, you should probably opt out of the service, as that is part of how the technology improves. We trust that they handle it professionally.
  
  

Withdrawal of Consent

As noted, you can withdraw consent to JotPsych at any time. To do so, simply inform your provider that you no longer want your sessions to utilize the AI scribe. It is best to also put this in writing (such as sending an email or signed note stating “I withdraw my consent for use of the JotPsych AI scribe in my sessions”). This creates a clear record.

Once consent is withdrawn, we will immediately stop enabling the SmartScribe system during your visits. This will have no effect on your ability to continue treatment with us; it just means the provider will revert to conventional note-taking. There is no penalty, and you will not be charged any fee related to discontinuing its use (note: we do not charge patients for using the AI either; it’s a tool on our side).

We will inform SmartScribe that your data should no longer be collected. Any data already collected cannot be retroactively deleted from our records (those are legal medical records) or from any backups SmartScribe had, but it will no longer be actively used except as part of past record. Typically, withdrawal just means going forward, nothing is sent to them.

Acknowledgement and Consent

We use JotPsych in your care, so by using our website, you are confirming the following:

• I have been informed about the use of JotPsych by SmartScribe Corp as an AI scribe tool during my medical sessions. I understand how it works and what it does with my protected health information.
  
  

• I understand the purpose is to aid in creating accurate medical notes and that it may improve the provider’s ability to focus on me. The potential benefits and any minimal risks to my privacy have been explained.
  
  

• I have had the opportunity to ask questions about JotPsych and all my questions have been answered to my satisfaction.
  
  

• I understand that my information will be handled according to HIPAA and applicable laws while using this service, and that I can review SmartScribe’s Terms of Use and Privacy Policy if I want more details.
  
  

• I understand that I can decline or withdraw from using the AI scribe at any time without any impact on the rest of my treatment.
  
  

• By giving this consent, I do not waive any of my rights under privacy laws, and I know this is a permission I am granting which I can also revoke.
  
  

• I hereby consent to the use of JotPsych by SmartScribe Corp during my psychiatric consultations and appointments with Six States Wellness Pllc by booking through this website and scheduling appointments and services.
  

Final Note: The above policies and consents are meant to protect your rights and inform you of our practices. We strive to provide high-quality care in a transparent and patient-centered way. If you have any questions or concerns about any policy or consent form, please do not hesitate to discuss them with us. Your comfort and trust are extremely important. Thank you for taking the time to review these documents. We look forward to working with you towards your health and wellness goals.

Informed Consent for Benzodiazepine Deprescription

Provider: Casey Brachvogel, CRNA, PMHNP-BC or TBD NP

Purpose and Rationale

You are currently taking a benzodiazepine medication (e.g., Xanax, Ativan, Klonopin). Your provider recommends a gradual deprescription (tapering off) of this medication. Long-term benzodiazepine use can lead to dependence and other risks, including cognitive decline, accidents, addiction, and withdrawal problems. Stopping benzodiazepines suddenly can be dangerous (it may cause severe withdrawal symptoms like seizures), so a slow, supervised taper is the safest approach. The goal of deprescription is to improve your long-term health and reduce dependence while minimizing withdrawal effects. By signing this form, you indicate that you understand the plan and consent to proceed with a benzodiazepine taper under the guidance of Casey Brachvogel, CRNA, PMHNP-BC.

Supportive Medications (Off-Label Use)

To help make the taper safer and more comfortable, off-label medications may be used. “Off-label” means a medication is being used for a purpose not officially approved by the FDA, but some research or experience suggests it may help. The following medications might be used to support your benzodiazepine withdrawal:

• Acamprosate (Campral): Originally used for alcohol dependence, acamprosate helps stabilize brain chemistry. Some evidence shows that it can reduce prolonged withdrawal symptoms such as anxiety and insomnia. Using acamprosate off-label may ease benzodiazepine withdrawal-related anxiety or sleep troubles.
  
  

• Baclofen: A muscle relaxant that activates GABA_B receptors. Baclofen’s action is related to the GABA system affected by benzodiazepines. Empirical use of baclofen (off-label) has shown it can help people reduce benzodiazepine use in cases of high. It may lessen withdrawal symptoms like muscle tension and cravings by providing a calming effect.
  
  

• Clonidine: A blood pressure medication that calms the sympathetic nervous system. Clonidine can relieve physical withdrawal symptoms such as rapid heartbeat, high blood pressure, sweating, and feelings of anxiety by reducing the body’s “adrenaline” responses. This can make you feel more comfortable during the taper. (Clonidine is commonly used off-label to ease withdrawal symptoms for various substances.)
  
  

• Ondansetron (Zofran): An anti-nausea medication that blocks 5-HT3 (serotonin) receptors. Ondansetron can help with nausea or stomach upset during withdrawal. Interestingly, it has also shown anxiolytic (anxiety-reducing) effects in some studies, meaning it might help reduce anxiety as you cut down the benzodiazepine. Ondansetron’s use in this context is off-label and intended to make withdrawal symptoms more tolerable.
  
  

Your provider will explain which (if any) of these medications are appropriate in your case. You will also be informed about common side effects of each supportive medication. Using these medicines is optional and meant to improve comfort; they are not a substitute for the benzodiazepine, but rather aids to manage symptoms.

Taper Plan and Provider Role

Taper Process: During the deprescription process, you will continue to receive benzodiazepine prescriptions, but at gradually reducing doses. The taper will be individualized based on your progress. Typically, dose reductions will be small and spread over weeks or months to minimize withdrawal symptoms. We will regularly review your symptoms and adjust the pace of taper if needed. In some cases, we may switch you from your current benzodiazepine to a longer-acting form (such as diazepam [Valium]) as part of a cross-taper strategy. Diazepam stays in the body longer, which helps prevent sharp withdrawal effects. Switching to a long-acting benzodiazepine via a stepwise crossover is a recognized method for safer tapering.. For example, if you are on alprazolam (a short-acting benzo), we might gradually replace it with an equivalent dose of diazepam, then taper the diazepam. Throughout the taper, Casey Brachvogel, CRNA, PMHNP-BC will monitor your condition closely. You will have follow-up appointments or check-ins to track withdrawal symptoms, provide support, and make any necessary adjustments.

Consultative Role of Provider: Casey Brachvogel or other Six States Wellness PLLC NPs are acting as a consultant for benzodiazepine tapering in this plan. This means he is not taking over as your primary mental health provider. You should continue to receive general psychiatric or therapy services from your primary mental health care provider (such as your psychiatrist, primary care doctor, or therapist). Casey’s role is specifically to manage the benzodiazepine deprescription and related support during this process. He can coordinate with your other providers as needed, but will not be managing other aspects of your mental health treatment outside of the scope of this taper. It’s important that you maintain contact with your regular mental health provider for ongoing care (for example, for therapy or managing antidepressants or other medications you may be on). This collaborative approach ensures you have comprehensive support: Casey will focus on the safe benzodiazepine taper, while your other providers continue to address your broader mental health needs.

Risks and Benefits of Deprescribing

Benefits: Tapering off benzodiazepines can improve your health in the long term. It may lead to better cognitive function (clearer thinking, better memory) and physical coordination. It removes the risk of long-term benzodiazepine side effects. Importantly, it reduces the risk of serious outcomes associated with chronic use of these drugs – for example, dependence and addiction (needing higher doses, difficulty stopping), accidents or falls (due to sedation or slowed reaction time), and interactions with other substances. Research has shown that long-term benzodiazepine use increases risks such as cognitive decline, motor vehicle accidents, hip fractures in older adults, and overdose (especially if combined with alcohol or opioids). By discontinuing benzodiazepines, you eliminate these medication-related risks. Many patients also report feeling empowered and more alert once off the medication, and some find that their baseline anxiety or sleep actually improves after an adjustment period (since benzodiazepines can sometimes worsen anxiety or insomnia in the long run due to tolerance).

Risks and Withdrawal Symptoms: Deprescribing benzodiazepines must be done carefully because of potential withdrawal symptoms. As your dose is lowered, you might experience temporary increases in anxiety, nervousness, or insomnia (difficulty sleeping) – basically, the symptoms the benzodiazepine was originally helping may rebound for a time. Other common withdrawal symptoms include irritability, restlessness, muscle tremors or shaking, sweating, headache, nausea, or upset. You could also experience palpitations (your heart beating fast or irregularly) or blood pressure changes as your body adjusts. In more severe cases, stopping benzodiazepines too quickly can lead to serious symptoms like hallucinations, seizures, or confusion. However, the plan we are following – a slow taper with possible supportive medications – is specifically designed to avoid these severe outcomes. By reducing the dose gradually and monitoring you closely, we greatly reduce the risk of dangerous withdrawal effects. It is important that you follow the plan and communicate any severe symptoms right away so we can adjust the taper if needed.

You should also know that everyone’s experience is different: some people have minimal withdrawal symptoms, while others may have more pronounced effects even with a slow taper. We will work together to manage any symptoms that arise. Supportive strategies like the medications listed above, as well as non-drug approaches (relaxation techniques, counseling, good sleep hygiene, etc.), can be used to cope with symptoms. If at any point the symptoms feel unmanageable, tell your provider – the taper speed can be paused or slowed to help you adjust. Your safety and comfort are the priority.

Alternatives: I understand that undergoing a benzodiazepine taper is optional. Alternatives to this plan include: (1) continuing the benzodiazepine as is (no change in your current regimen), recognizing that this carries ongoing risks of long-term use; or (2) discussing other treatments for your condition (for example, therapy or non-benzodiazepine medications for anxiety or insomnia) instead of tapering the benzodiazepine at this time. Another alternative could be seeking a second opinion or care from a specialist in addiction medicine or another provider. The decision to proceed with deprescribing now is made in consultation with you – it is a voluntary choice to improve your health. If you choose not to go through with the taper, your provider will discuss other ways to manage your care. There is no penalty for deciding against this plan; however, the benefits of stopping benzodiazepines (as listed above) would not be realized if you continue on the medication. We encourage you to make an informed decision that you are comfortable with.

Consultation and Questions: You have the right to ask any questions about this plan. Please feel free to discuss all your concerns with Casey or any other healthcare provider on your team. It’s important that all your questions are answered to your satisfaction. You also have the right to withdraw your consent and stop the taper process at any time. If you decide to halt the taper, we will work with you on the next steps (which might include maintaining the current dose or exploring other options). Your participation in this deprescribing plan is entirely voluntary.

Patient Acknowledgment and Consent

By signing below, I acknowledge that I have read and understood the information in this consent form. The provider has explained to me in plain language why a benzodiazepine taper (deprescription) is recommended in my case, the nature of the tapering plan, and the use of off-label support medications including acamprosate, baclofen, clonidine, and ondansetron. I understand the risks of continuing long-term benzodiazepine use, as well as the potential risks and discomforts of tapering, and I understand the expected benefits of getting off this medication. I have been informed of possible alternatives (including not changing my current regimen). All of my questions have been answered. I understand that Casey Brachvogel, CRNA, PMHNP-BC, or other Six States Wellness PLLC NPs will act as a consultant/s for this specific purpose and not as my primary mental health provider. I agree to continue my general mental health care with my regular provider while working with Casey on the benzodiazepine taper. I willingly give my informed consent to begin the benzodiazepine deprescribing plan, and I understand I can change my mind and revoke this consent at any time.