ESA Letter Renewal

1. I understand that Pet Connect will provide administrative services to connect me with a licensed mental health professional via our online platform (“the LMHP”) to engage in a telehealth consultation. 2. I understand that telehealth technology that will be used to affect such a consultation will not be the same as a direct client/health care provider visit because I will not be in the same room as my provider. 3. I understand that a telehealth consultation has potential benefits including easier access to care and the convenience of meeting from a location of my choosing. 4. I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that the LMHP or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation. 5. I understand that I have a right to confidentiality with Telehealth under the same laws that protect the confidentiality of my personal and health information for in-person behavioral health services. Any information disclosed by me during my remote Telehealth, therefore, is generally confidential to the extent provided by law. 6. I understand and agree that this website is not an emergency-response or emergency-monitoring service and any person who is aware of an emergency situation or believes that a person may be at risk of injury or death or who may harm themselves or another person should immediately contact an appropriate emergency responder or dial “911” on a phone. Pet Connect is under no obligation to monitor or respond to communications made to, on or through this website and no user or person should rely on the website for medical or behavioral health advice or emergency services.

By clicking yes below, I authorize the licensed mental health professional and their employees and agents (collectively "Licensed Mental Health Professional") to give my medical information as described below to Pet Connect, LLC, and I authorize Pet Connect, LLC to provide medical information that I provide to Pet Connect, LLC to the licensed mental health professional. Description of information to be used or disclosed: the Emotional Support Animal (ESA) letter (the "Letter") provided by the Licensed Mental Health Professional, if one, and all records and medical or mental health information related to the Letter or related to the evaluation by the Licensed Mental Health Professional, including without limitation all information, opinions, diagnoses, assessments, notes, and documentation related to such assessment, and the Letter including any pre-screening or demographic information provided to Pet Connect, LLC by me. Purpose of the disclosure: I am requesting this information be disclosed for any purpose deemed necessary or advisable by Pet Connect, LLC. I understand that if my information is given out as allowed on this form, Pet Connect, LLC is not subject to federal privacy laws and may re-disclose my information. Therefore, those laws will not protect my information. This form expires 5 years after the date I provide authorization, by clicking yes below. I understand I have the right to withdraw permission for the release of my information. If I provide authorization to use or disclose information, I can revoke that authorization at any time. I understand the revocation must be made in writing to my Licensed Mental Health Professional at the address indicated on the Letter, and I am authorizing the release of my information voluntarily, and treatment, payment, or my eligibility for benefits will not be affected if I do not sign this authorization. I agree that a copy of this authorization may be treated as a signed document.

Pet Connect and the licensed mental health therapist you are connected with will keep your answers strictly confidential. Your privacy is important to us and we take it seriously. This form is solely used to inform the mental health therapist you are connected with to contact you. By completing this form and pressing submit, you understand that the maker and provider of this form does not take responsibility for any liability, loss, or risk incurred as a consequence, directly or indirectly, from the use and application of any of this material. The actions of an emotional support animal are the full responsibility of its owner.