Service Agreement
Covered Entities: 247DCT LLC (the management services organization), Ghadeer Counseling Services PC, Jessica N Baker PLLC, Digital Care Team of OH LLC, Alabama Psychiatry & Therapy LLC, Mountain Valley Counseling PC, Mind Spring SC, COGNIVIA Mental Health SC, Pure Medical Group LLC, and their affiliates (collectively, the "Behavioral Healthcare Entities," and together with 247DCT LLC, "24/7 DCT," "we," or "us").
Allocation of Roles and Responsibilities. 247DCT LLC is the management services organization. 247DCT LLC provides administrative, operational, technology, billing, scheduling, marketing, compliance, and management support services ONLY. 247DCT LLC is not a healthcare provider; does not own or control the clinical practice of medicine, behavioral health, or any other licensed health profession; does not employ or supervise the licensed clinicians who render care; and is not a party to the patient-clinician therapeutic relationship. All clinical care — including diagnosis, treatment, prescribing, psychotherapy, psychiatric evaluation, counseling, and any other professional clinical service — is rendered exclusively by the Behavioral Healthcare Entities and the licensed clinicians they employ or contract with. Each Behavioral Healthcare Entity is independently owned and controlled by a licensed clinician or group of licensed clinicians as required by the corporate-practice-of-medicine laws of the relevant state.
My clinical relationship is with the licensed clinician and the Behavioral Healthcare Entity rendering my care, not with 247DCT LLC. Any claim arising from clinical care must be brought against the rendering clinician and the applicable Behavioral Healthcare Entity, not against 247DCT LLC. 247DCT LLC is a third-party beneficiary of this Agreement with the right to enforce its terms against me, but the Behavioral Healthcare Entities and clinicians retain primary contractual privity with respect to clinical services.
This Client Service Agreement (“Agreement”) sets forth the terms and conditions under which 24/7 DCT provides outpatient behavioral health services. By signing below, you acknowledge that you have read, understand, and agree to the terms of this Agreement. This Agreement is a legally binding contract between you and 24/7 DCT.
Eligibility — Geographic Limitation. 24/7 DCT provides services ONLY to patients who are physically located in the State of Illinois, the State of Ohio, or the State of Alabama at the time of each service encounter. 24/7 DCT does NOT provide services to patients in any other U.S. state, U.S. territory, or foreign country. By entering into this Agreement, I represent that I am physically located in Illinois, Ohio, or Alabama; that I will remain in one of these three states during all service encounters; and that I will not access 24/7 DCT services from any other location. If my physical location changes such that I am no longer in Illinois, Ohio, or Alabama, I will notify 24/7 DCT immediately, and 24/7 DCT may suspend, modify, or terminate services.
Eligibility — Age. I am at least 18 years of age, OR a parent, legal guardian, or other authorized representative is signing this Agreement on behalf of a minor patient or an adult patient lacking decisional capacity. If signing on behalf of another, I represent that I have legal authority to do so under applicable state law (e.g., parental or guardianship rights, healthcare power of attorney, court order). I will provide documentation of my authority upon request, and I will indemnify 24/7 DCT for any loss arising from my misrepresentation of authority.
NOT FOR EMERGENCIES. 24/7 DCT IS NOT AN EMERGENCY SERVICE. IF I AM EXPERIENCING A MEDICAL OR PSYCHIATRIC EMERGENCY, INCLUDING BUT NOT LIMITED TO THOUGHTS OF SUICIDE, SELF-HARM, HARM TO OTHERS, OVERDOSE, ACUTE PSYCHOTIC SYMPTOMS, OR ANY LIFE-THREATENING SITUATION, I WILL CALL 911 IMMEDIATELY OR GO TO THE NEAREST EMERGENCY ROOM. I MAY ALSO CALL OR TEXT 988 (THE 988 SUICIDE & CRISIS LIFELINE) OR TEXT "HOME" TO 741741 (THE CRISIS TEXT LINE). 24/7 DCT'S SCHEDULED TELEHEALTH SERVICES ARE NOT DESIGNED FOR, AND CANNOT REPLACE, EMERGENCY MEDICAL OR PSYCHIATRIC INTERVENTION. 24/7 DCT IS NOT LIABLE FOR ANY HARM ARISING FROM MY FAILURE TO SEEK EMERGENCY CARE WHEN NEEDED.
I. GENERAL CONSENT FOR CARE AND TREATMENT
I hereby give my consent for 24/7 DCT and its professional staff to provide health care services to me (or to the patient named below, if I am signing as a parent, legal guardian, or authorized representative). I understand that the practice of medicine and behavioral health care is not an exact science and that no guarantees have been made to me regarding the outcome of any examination, test, treatment, or procedure. I acknowledge that my provider will explain the nature and purpose of any proposed treatment, the potential risks and benefits, and any available alternatives, and that I have the right to ask questions at any time.
This consent extends to all 24/7 DCT locations, entities, and affiliated providers listed above, as well as any satellite office, telehealth platform, or other setting through which 24/7 DCT delivers services. I understand that 24/7 DCT providers may change over the course of my treatment and that I will be notified of any such change. This consent shall remain in effect for all services provided by 24/7 DCT until revoked by me in writing.
II. INFORMED CONSENT TO OUTPATIENT MENTAL HEALTH SERVICES
A. Individual Outpatient Services
I authorize 24/7 DCT and its professional staff to provide all necessary outpatient mental health services to me, including but not limited to counseling, psychotherapy, psychological evaluation, diagnostic assessment, and medication management (where applicable). I understand that outpatient mental health services carry both benefits and risks.
Potential Benefits
- Increased insight and understanding of current challenges
- Improved coping skills for managing negative emotions and difficult situations
- Strengthened positive experiences and interpersonal relationships
- Enhanced problem-solving, acceptance, and resolution skills
- Reduction in symptoms of mental health conditions
Potential Risks
- Experiencing uncomfortable or distressing feelings such as anger, frustration, anxiety, sadness, fear, guilt, or helplessness
- Temporary increase in emotional distress as traumatic or difficult topics are explored
- Changes in relationships as personal growth occurs
- No guarantee of specific outcomes; additional referrals may be warranted
I understand that successful treatment depends on my willingness to engage openly with my provider, maintain consistent attendance, communicate honestly about my experience and needs, and actively participate in the therapeutic process. I understand that I may discontinue treatment at any time, though I am encouraged to discuss any concerns with my provider before doing so.
Medication Management: If my treatment includes psychiatric medication management, I understand that medications may have side effects, that response to medication varies among individuals, and that my prescribing provider will discuss the risks, benefits, and alternatives of any recommended medication with me before prescribing. I agree to take medications only as prescribed, to report any side effects promptly, and to not stop or adjust medication without consulting my provider. Failure to follow the instructions of the prescribing provider may result in termination of services. 24/7 DCT providers will not prescribe controlled substances as part of an initial telehealth encounter unless permitted by applicable state and federal law.
B. Minor Patients
If the patient is a minor unable to consent to treatment independently, I, as the parent or legal guardian, authorize treatment and understand the unique considerations that apply. Under Illinois law, a minor age 12 or older may consent to a limited number of outpatient counseling and psychotherapy sessions without parental consent (405 ILCS 5/3-501); the statute caps the number of sessions and session length before parental notification is required, and this limited self-consent does NOT extend to psychiatric evaluation, medication management, prescribing, or any service other than outpatient counseling or psychotherapy. Separate from the consent-to-treatment framework, a minor age 12 or older has rights under 740 ILCS 110/4 to access and authorize the release of their own mental health records, subject to the parent's right to certain summary information and the therapist's compelling-reasons exception. For all services beyond the statute's session cap, and for all services not covered by 405 ILCS 5/3-501, parental or legal guardian consent is required, documented through the Minor Patient Addendum.
Custody Documentation: If there is a custody order that limits either parent’s access to the minor’s medical records or participation in treatment decisions, a copy of the relevant court order must be provided to 24/7 DCT before the first appointment. 24/7 DCT will comply with valid court orders regarding custody and access.
Additional details regarding the treatment of minor patients are set forth in the Minor Patient Addendum, which must be completed prior to the first service appointment.
C. Couples Mental Health Services
If I am participating in couples therapy, I understand that it may involve the experiencing of difficult emotions. Therapy often requires discussion of challenging relationship dynamics, and it is possible that the relationship may seem to worsen before improvement as each partner undergoes personal change. I understand that information shared in couples sessions is part of the couples’ treatment record and may be accessible to both partners. Additional referrals, including to individual services, may be recommended.
III. TELEHEALTH SERVICES
I understand that 24/7 DCT providers may deliver services via telehealth modalities when clinically appropriate and permitted by state and federal law. Telehealth means the delivery of health care services using interactive audio, video, or other electronic communications technology when the provider and patient are not in the same physical location. This section supplements, and does not replace, my general consent to treatment.
A. Benefits of Telehealth
- Convenient access to care from a remote location, reducing travel time and costs
- More efficient, timely, and cost-effective evaluation and management
- Access to specialist expertise that might not otherwise be available locally
- Continuity of care during situations that prevent in-person visits
B. Risks and Limitations
- Services may not be as comprehensive as in-person visits for certain clinical needs
- Technology-related risks including interruptions, unauthorized access, and technical difficulties; 24/7 DCT is not liable for technology failures
- Either party may discontinue the telehealth encounter if the technology is not adequate
- Potential for cultural, language, or time-zone differences that may affect service delivery
- Possible denial of insurance benefits for telehealth encounters
- My provider may determine at any time that telehealth is not clinically appropriate for my care and may recommend in-person services
C. Patient Rights and Responsibilities
- I may withdraw consent to telehealth at any time without affecting my right to future care
- All confidentiality protections apply equally to telehealth encounters
- My sessions will not be recorded without my express consent
- I will be informed if any person other than my provider is present during the session
- I will be provided with my provider’s credentials, license number, physical location, and contact information
- I am responsible for ensuring my environment is private during telehealth sessions
- I will provide my current physical location at the start of each telehealth session for emergency response purposes
I acknowledge that telehealth services require my provider to be licensed in the state where I am physically located at the time of the session. I am physically located in Illinois, Ohio, or Alabama, and I will continue to be physically located in one of these three states during all telehealth sessions. If I travel out of state, I agree to inform 24/7 DCT in advance, and I understand that services may be modified, postponed, or terminated if my provider is not licensed in the state where I will be located. I will not log into a telehealth session from a state other than Illinois, Ohio, or Alabama. I will provide my exact physical location (city and state) at the start of each telehealth session, and I understand that 24/7 DCT will document this location in my medical record consistent with applicable state law (Illinois telehealth rules; Ohio Admin. Code 4731-37-01 and Chapter 5122-29-31; Ala. Code §§ 34-24-700 through 34-24-707).
State-Specific Telehealth Disclosures. The following state-specific telehealth provisions apply based on the state in which I am physically located:
Illinois patients. Telehealth services rendered to Illinois patients are subject to the Illinois Telehealth Act (225 ILCS 150/) and applicable IDFPR licensing-board rules. Illinois law requires informed consent for telehealth, which is satisfied by this Section III; verification of patient identity at each encounter; documentation of clinician location and patient location; and compliance with the Mental Health and Developmental Disabilities Confidentiality Act (740 ILCS 110/) for behavioral health records.
Ohio patients. Telehealth services rendered to Ohio patients are subject to Ohio Revised Code § 4731.74 (physician telemedicine), Ohio Admin. Code 4731-37-01 (medical board telemedicine rules), Ohio Admin. Code Chapter 5122-29-31 (behavioral health Medicaid telehealth rules), and the licensing-board rules for the rendering clinician's profession (e.g., 4757 for counselors and social workers; 4732 for psychologists; 4723 for advanced practice registered nurses). I acknowledge that informed consent for telehealth is required under Ohio law and is satisfied by this Section III; that the rendering clinician must be licensed in Ohio (or be exempt from licensure under R.C. § 4743.09 or other applicable provision); that telehealth services delivered through audio-only communication are subject to additional limitations; and that 24/7 DCT will comply with Ohio's privacy and security requirements for telehealth.
Alabama patients. Telehealth services rendered to Alabama patients are subject to the Alabama Telehealth Medical Services Act (Ala. Code §§ 34-24-700 through 34-24-707) and Ala. Admin. Code 540-X-25 (telemedicine rules). I acknowledge that under Ala. Code § 34-24-703(c), the provision of telehealth medical services is deemed to occur at my originating site within Alabama; that any claim for medical malpractice arising from such services shall be governed by the Alabama Medical Liability Act of 1987 (Ala. Code §§ 6-5-540 through 6-5-552) and shall be venued in the circuit courts of Alabama as required by Ala. Code § 34-24-703(a); that the rendering physician must be licensed in Alabama or qualify for an irregular-or-infrequent-services exception under Ala. Code § 34-24-702; that under Ala. Code § 34-24-703(f), if a physician or practice group provides telehealth services to me more than four times in a 12-month period for the same medical condition without resolution, the physician shall either see me in person within 12 months or appropriately refer me to an in-person provider; and that for controlled-substance prescribing, additional limitations apply under Ala. Code § 34-24-705 and Alabama Board of Medical Examiners rules.
Identity Verification. I acknowledge that 24/7 DCT will verify my identity at each telehealth encounter consistent with applicable state law and that 24/7 DCT may use government-issued identification, biometric verification, knowledge-based authentication, or other reasonable means for this purpose. I will cooperate with reasonable identity-verification requests and acknowledge that failure to verify identity may result in service refusal.
- I am responsible for maintaining a charged device, functioning camera and microphone, and reliable internet connection
- I will not record any portion of a telehealth session without my provider’s express written consent
D. Technology and Security
24/7 DCT uses HIPAA-compliant telehealth platforms employing encryption and security safeguards. However, no technology is completely secure, and 24/7 DCT cannot guarantee absolute protection against unauthorized access. I am responsible for obtaining and maintaining the software, hardware, and internet connectivity necessary to participate in telehealth sessions. I understand that my use of public or unsecured Wi-Fi networks may increase the risk of unauthorized access to my communications.
IV. COMMUNICATION & CONSENT TO CONTACT
A. Text and Email Communications
I consent to receive communications from 24/7 DCT via text message and email regarding appointment reminders, service updates, and other important communications at the phone number and email address I have provided. I understand that:
- My consent is not a condition of receiving services
- Message and data rates may apply
- I can stop text messaging at any time by sending STOP and get help by sending HELP
- Unencrypted email and SMS are not fully secure and may be intercepted
- If someone else has access to my email account, phone, or device, they may see health-related communications
- These forms of unauthorized access could reveal that I am receiving behavioral health care and, combined with other information, could lead to medical identity theft
A(1). Marketing Communications — Separate Consent Required.
Separate from the transactional communications described above (appointment reminders, refill notices, billing communications, treatment-related communications, and other operational messages), 24/7 DCT may also send marketing communications by SMS or email. Marketing communications include promotional offers, new service announcements, educational content unrelated to my specific care, and similar promotional messages. Marketing communications require my SEPARATE, AFFIRMATIVE, ONE-TO-ONE consent under the Telephone Consumer Protection Act (47 U.S.C. § 227) and FCC implementing regulations (47 C.F.R. § 64.1200), including the FCC's one-to-one consent rule. I will be presented with a separate marketing-consent box at intake. I may consent or decline; declining marketing communications will not affect my treatment or transactional communications. I may opt out of marketing communications at any time by replying STOP to any marketing SMS, clicking "unsubscribe" in any marketing email, or contacting 24/7 DCT in writing. Opting out of marketing communications does not opt me out of transactional communications, which are necessary to support my care.
Marketing Consent Block. By initialing here, I AFFIRMATIVELY CONSENT to receive marketing SMS and marketing email from 24/7 DCT at the phone number and email address I have provided. I understand that marketing communications are not a condition of treatment and that I may decline or revoke this consent at any time. Initials: __________________ [ ] I DECLINE marketing communications.
If you are not comfortable accepting these risks, please notify our office in writing, and we will limit electronic communications to secure methods only.
B. Telephone Call Recording
24/7 DCT may record inbound and outbound telephone calls for quality monitoring, training, and documentation purposes. By continuing a telephone conversation with 24/7 DCT, you consent to the recording of that call. You may request that any call not be recorded.
C. Voicemail and Messages
I authorize 24/7 DCT to leave voicemail messages at the telephone number(s) I have provided regarding appointment reminders, follow-up care, billing, and other service-related communications. I understand that voicemail messages may be heard by others with access to my phone.
V. PATIENT CODE OF CONDUCT
24/7 DCT is committed to providing a safe, respectful, and therapeutic environment for all patients and staff. By accepting services from 24/7 DCT, I agree to the following standards of conduct:
- I will treat all 24/7 DCT staff and providers with courtesy and respect
- I will provide accurate and complete information regarding my identity, medical history, insurance, and contact information, and will promptly update this information if it changes
- I will not engage in rude, disrespectful, threatening, violent, or discriminatory behavior toward any 24/7 DCT personnel
- I will not misrepresent my identity or provide false information to obtain services
- I will not seek multiple consultations within the same day for the same issue to circumvent clinical recommendations
- I will not share my login credentials or account access with any other person
Consequences: If my behavior causes concern for the safety or well-being of staff or other patients, 24/7 DCT will remind me of these standards. Excessive or repeated violations may result in transfer to another provider, suspension of access to telehealth platforms, or discontinuation of therapy, in accordance with applicable legal and ethical requirements. 24/7 DCT will take appropriate steps to ensure coordination and continuity of care in the event services are discontinued.
VI. APPOINTMENT & CANCELLATION POLICY
Regular attendance at scheduled appointments is essential to successful treatment. If you cannot attend a scheduled appointment, you must cancel at least 48 hours (2 business days) in advance. Saturdays, Sundays, and national holidays are not considered business days; notice of cancellation provided on those days will be deemed received on the next business day.
Failure to provide adequate notice will result in a cancellation or no-show fee, as outlined in Section VII below. This policy applies in all circumstances unless prohibited by law or by our agreement with your insurer.
VII. FINANCIAL POLICY
A. General
24/7 DCT maintains a fee schedule for each provider identifying the price of various services. Payment is expected and required for all services rendered regardless of insurance coverage. Patients are required to provide a valid government-issued ID and current insurance card at each visit.
B. Insurance
Patient Payment Obligation: I understand that insurance coverage is a contract between myself and my insurance company and is not a guarantee of payment. Claims may be denied for various reasons including non-eligibility, non-covered services, or failure to obtain pre-authorization. Regardless of insurance coverage, I am fully responsible for all charges for services rendered to me or my dependents at 24/7 DCT that are not covered by my insurance company.
Copays, Deductibles, and Coinsurance: I understand that 24/7 DCT is required by contract with insurance companies to collect any applicable copayment, coinsurance, and unmet deductible at the time of service. The amount collected at time of service is an estimate based on available benefit information. Once my claim is processed, I may owe additional amounts, which will be due immediately and may be charged to my credit card on file.
Pre-Authorization: If required by my insurance, I am responsible for obtaining any necessary referrals, pre-authorizations, and pre-certifications prior to services. I am responsible for payment of balances resulting from failure to obtain required authorizations.
C. Self-Pay / No Insurance
If I do not have insurance or am unable to provide valid insurance, I agree to be treated as a cash-pay patient and must pay for all services at the time of service. I will be responsible for filing any paperwork for reimbursement on my own account.
D. Fee Schedule
- Service: Late Cancellation (Cash Pay) Description: Less than 48 hours / 2 business days Fee: Cost of Appt
- Service: Late Cancellation (Insurance) Description: Less than 48 hours / 2 business days Fee: $100.00
- Service: No-Show (Cash Pay) Description: Failure to attend Fee: Cost of Appt
- Service: No-Show (Insurance) Description: Failure to attend Fee: $100.00
- Service: Educational / Evaluation Description: Testing/assessments not covered by insurance Fee: $175/hour
- Service: Collateral Service Description: Meetings, conferences, or letters Fee: $25/15 min
- Service: Legal Fees Description: Testimony, summons, subpoenas, or any work considered to be legal in nature Fee: $175/hour
- Service: Records Release Description: Per request Fee: $6.50
- Service: Returned Check Description: Checks returned/unpaid Fee: $30.00
Carve-Outs and Accommodations: The cancellation and no-show fees in this schedule do NOT apply to (a) Medicaid patients (under 42 C.F.R. § 447.15) or (b) Original Medicare patients except where the same fee schedule is applied uniformly to all patients (Medicare and non-Medicare alike) and the fee is not billed to Medicare. Reasonable accommodations will also be made for cancellations due to disability-related reasons, severe weather, medical emergencies, or other circumstances beyond the patient's control, consistent with Section 1557 of the Affordable Care Act and Title III of the Americans with Disabilities Act.
E. Non-Payment and Collections
If I fail to pay any amount due, 24/7 DCT may refer my account to a collections agency and/or pursue legal remedies. I understand that if my account is sent to collections, I will be responsible for all collection costs, administrative fees, court costs, and attorney fees incurred in the collection of my outstanding balance. Chargebacks or disputes of legitimate charges will result in involvement of 24/7 DCT’s legal team, and I may be responsible for all associated costs.
F. Good Faith Estimate (No Surprises Act)
Under the No Surprises Act (Public Law 116-260), you have the right to receive a Good Faith Estimate of expected charges for scheduled or requested health care items and services. If you are uninsured or self-pay, you will receive a Good Faith Estimate in writing at least one (1) business day before your service or upon scheduling, whichever is earlier. If you receive a bill that is at least $400 more than your Good Faith Estimate, you may dispute the bill. For questions, visit www.cms.gov/nosurprises.
VIII. PROFESSIONAL RELATIONSHIP
To maintain an appropriate professional and therapeutic relationship, 24/7 DCT providers will not socialize with or maintain personal relationships with clients outside of treatment. Sexual intimacy between a provider and client is never appropriate and must be reported to the applicable Illinois licensing board. Mutually respectful engagement is critical to a successful therapeutic relationship.
If you have concerns about how your provider is treating you, you are encouraged to raise them directly, and 24/7 DCT personnel will address them promptly.
IX. PRIVACY, CONFIDENTIALITY, AND RECORDS
Communications in the context of a therapist-patient relationship are generally confidential. Records will be maintained in accordance with the strictest level of confidentiality applicable under federal and state law, including the Illinois Mental Health and Developmental Disabilities Confidentiality Act (740 ILCS 110/). Your provider generally cannot disclose information about you or your care without your consent. However, law provides exceptions where information may be disclosed, including:
- An emergency arises in which the therapist determines disclosure is necessary to protect the patient or others from a clear, imminent risk of serious physical or mental injury, disease, or death (740 ILCS 110/11(ii))
- A judge issues a court order requiring disclosure
- A professional suspects child or elder abuse or neglect
- Criminal or delinquency proceedings where assessment or therapy is court-ordered
- Disclosure is necessary for treatment continuity within an episode of care subject to the documentation and notice requirements of 740 ILCS 110/9.4
- Disclosure to a payor of the limited information necessary to receive third-party payment, consistent with 740 ILCS 110/9.2 (which permits disclosure of billing data only and prohibits re-disclosure)
- Mandatory reports required by law, including suspected abuse or neglect of children under the Abused and Neglected Child Reporting Act (325 ILCS 5/), suspected abuse, neglect, or financial exploitation of adults age 60 and older or adults with disabilities under the Adult Protective Services Act (320 ILCS 20/), and communicable disease reporting required by the Illinois Department of Public Health
Couples Records: Records for couples seeking counseling as a couple will be maintained in a single record under the name of the financially responsible member. In the event that the financially responsible member is also separately a client receiving individual treatment, records will be segregated, and the other member of the couple will be able to access only records from joint sessions.
X. EMERGENCY SERVICES
24/7 DCT does not provide emergency or crisis services. If you or a family member are in a life-threatening situation, please take the following steps immediately:
- Call 911 or go to your nearest emergency room.
- 988 Suicide and Crisis Lifeline: Call or text 988 (available 24/7).
- Crisis Text Line: Text HOME to 741741.
Do not use 24/7 DCT’s telehealth platform, patient portal, email, or text messaging to communicate emergencies. These channels are not monitored in real-time and are not appropriate for emergency communications.
XI. ILLINOIS STATE ADDENDUM & DISCLOSURE
A. Provider Credentials
24/7 DCT professional staff consists of Licensed Clinical Professional Counselors (LCPC), Licensed Professional Counselors (LPC), Licensed Clinical Social Workers (LCSW), Licensed Marriage and Family Therapists (LMFT), Licensed Social Workers (LSW), and other licensed behavioral health professionals. The credentials and affiliations of your specific provider are available at: https://247dct.org
B. Patient Rights Under Illinois Law
- You are entitled to receive information about your diagnosis, your provider’s methods and techniques, expected duration of therapy, and the cost of treatment.
- You may seek a second opinion from another licensed professional, refuse recommended treatment, withdraw consent, or terminate therapy at any time.
- You are entitled to an explanation of the risks and benefits of treatment and the potential consequences of declining or stopping treatment.
- Sexual intimacy between a provider and client is never appropriate and must be reported to the applicable Illinois licensing board.
- Under the Illinois Mental Health and Developmental Disabilities Confidentiality Act (740 ILCS 110), all mental health records and communications are confidential and may not be disclosed except as provided by law.
- Under 740 ILCS 110/4, an adult recipient (age 18 and older) has the right to inspect and copy their mental health records. A recipient age 12 to 17 also has the right to inspect and copy their own records. The parent or legal guardian of a recipient age 12 to 17 has the right to access certain summary information, including diagnosis, treatment needs, services provided, and medications, except where the recipient objects and the therapist does not find compelling reasons to override the objection. The therapist may also withhold specific session content where compelling clinical reasons exist. Indigent patients are entitled to one free copy of records under 740 ILCS 110/4(b). You may also request amendment of inaccurate or misleading information.
- You have the right to be informed of the estimated cost of treatment before services are rendered.
- You have the right to be treated with dignity and respect, free from discrimination.
- You have the right to opt out of having your health information transmitted to or through a Health Information Exchange (HIE) under 410 ILCS 50/3.1. Mental health records, HIV/AIDS records, and genetic information are subject to additional opt-out protections under 740 ILCS 110/9.6, 410 ILCS 305/9.6, and 410 ILCS 513/31.8 respectively. To exercise this right, please notify our Records Custodian in writing.
- You have the right to heightened protection of reproductive health information and gender-affirming care information under the Illinois Reproductive Health Act (775 ILCS 55/) and Section 8-802.1 of the Code of Civil Procedure. 24/7 DCT will follow Illinois shield-law protections in responding to out-of-state subpoenas, civil investigative demands, or other legal process seeking these categories of records.
C. State-Specific Addenda
I acknowledge that I have accessed and reviewed any state-specific addendum applicable to the 24/7 DCT behavioral health entity providing my care. State-specific addenda, where applicable, are available at https://247dct.org and upon request.
XII. RECORD RETENTION
24/7 DCT maintains medical records in compliance with applicable federal and state requirements:
- Adult patient records: minimum of ten (10) years from the date of last patient encounter.
- Minor patient records: until the patient reaches age 25, or ten (10) years from the last encounter, whichever is longer.
- Records involved in pending litigation will be retained until the litigation is resolved.
- HIPAA administrative documents (privacy policies, procedures, BAAs): six (6) years from creation or last effective date.
XIII. MODIFICATION OF THIS AGREEMENT
24/7 DCT reserves the right to modify this Agreement at any time. Updated versions will be posted on our website and made available at our clinic locations. Your continued use of 24/7 DCT services after any modification constitutes your acceptance of the modified terms. Material changes will be communicated to you in writing or through the patient portal.
Notice of Material Amendments. For any material amendment to this Agreement, 24/7 DCT will provide at least thirty (30) days' advance notice to me by email and through the patient portal, identifying the changes and the effective date. If I object to a material amendment, I may terminate my use of services under the continuity-of-care provisions of Section XXIII, but my continued use of services after the effective date of the amendment constitutes my acceptance of the amended terms.
XIV. GOVERNING LAW
This Agreement shall be governed by and construed in accordance with the laws of the State of Illinois, without regard to conflict-of-laws principles, and applicable federal law including HIPAA, the HITECH Act, and the No Surprises Act.
Venue. Any action arising out of or relating to this Agreement shall be venued exclusively in the Circuit Court of Cook County, Illinois, or, where federal jurisdiction exists, the United States District Court for the Northern District of Illinois, Eastern Division. The parties consent to personal jurisdiction in those courts and waive any defense of inconvenient forum. Notwithstanding the foregoing, claims for medical malpractice arising from telehealth medical services rendered to a patient physically located in Alabama shall be venued in the circuit courts of the State of Alabama as required by Ala. Code § 34-24-703(a) and Sections 6-5-540 through 6-5-552 of the Alabama Code (the Alabama Medical Liability Act of 1987).
XIV(A). ACCOUNT AND PLATFORM TERMS OF USE
Account Creation and Credentials. To access 24/7 DCT services, I will create an account on the 24/7 DCT patient portal or telehealth platform. I will provide accurate, current, and complete information when creating my account and will keep that information up to date. I am solely responsible for safeguarding my account credentials (username, password, multi-factor authentication tokens). I will not share my account or credentials with any other person. If I have reason to believe my account has been compromised, I will notify 24/7 DCT immediately. I am responsible for all activity that occurs under my account, except where 24/7 DCT itself is grossly negligent.
Acceptable Use. I will use the 24/7 DCT platform only for the lawful, intended purposes of receiving healthcare services and managing my care. I will NOT: (a) use the platform to harass, abuse, threaten, or impersonate any person; (b) attempt to access any portion of the platform I am not authorized to access, including other patients' records; (c) reverse engineer, decompile, scrape, crawl, or otherwise attempt to extract source code, data, or content from the platform; (d) introduce any virus, malware, ransomware, or other harmful code into the platform; (e) use any automated system (bot, scraper, spider) to access the platform; (f) use the platform for any commercial purpose unrelated to my own care; (g) reproduce, distribute, sell, or otherwise exploit any content from the platform; or (h) use the platform in any manner that violates federal, state, or local law.
Intellectual Property. The 24/7 DCT platform, website, mobile applications, and all content (other than my own personal health information and content I submit) are owned by 24/7 DCT or its licensors and are protected by copyright, trademark, patent, trade secret, and other intellectual property laws. I receive no ownership rights in any 24/7 DCT intellectual property. 24/7 DCT grants me a limited, non-exclusive, non-transferable, revocable license to access and use the platform solely for purposes of receiving care.
User-Generated Content License. I retain ownership of any content I submit to the platform (messages, photos, voice notes, intake responses, journal entries, uploaded documents). I grant 24/7 DCT a perpetual, irrevocable, worldwide, royalty-free, sublicensable license to use, reproduce, store, modify, and display this content for the purposes of (a) providing my care, (b) operating the platform, (c) compliance and audit, (d) defending the practice in any claim, (e) producing aggregated, de-identified analytics consistent with HIPAA's de-identification standard at 45 C.F.R. § 164.514(b), and (f) any other use permitted by law or by my separate authorization. This license survives termination of my use of the platform.
Platform Availability. 24/7 DCT does not guarantee that the platform will be available at all times. The platform may be unavailable due to scheduled maintenance, unscheduled outages, technology failures, third-party dependencies, or events of force majeure. 24/7 DCT is not liable for any harm arising from platform unavailability except to the extent 24/7 DCT's own gross negligence is the proximate cause.
Account Suspension. 24/7 DCT may suspend my account, with or without notice, pending investigation of any suspected misuse, fraud, security concern, or violation of this Agreement. Account suspension is in addition to, and does not waive, the termination rights set forth in Section XXIII.
Mobile Application License. If I download a 24/7 DCT mobile application, I also agree to comply with the terms of service of the applicable application store (Apple App Store, Google Play). 24/7 DCT may push notifications, updates, and patches to the mobile application; my continued use of the application after such updates constitutes acceptance of those updates.
(see Section XXXII below for the formal Severability provision and Section XXXIII for Survival).
XV. LIMITATION OF LIABILITY
EXCEPT for claims of medical malpractice or professional clinical negligence, which are not subject to this Section XV: (a) the maximum aggregate liability of 24/7 DCT, its affiliates, providers, employees, and agents to the patient for any and all claims arising out of or relating to this Agreement, the services rendered, or the parties' relationship — including but not limited to claims for breach of contract, technology or platform failure, communication errors, billing errors, scheduling failures, lost data, breach of confidentiality not constituting clinical negligence, alleged misrepresentation, intentional infliction of emotional distress in non-clinical contexts, and tortious interference — shall not exceed the total amount the patient has paid 24/7 DCT for services rendered in the twelve (12) months immediately preceding the event giving rise to the claim; (b) in no event shall 24/7 DCT or any of its affiliates, providers, employees, or agents be liable for any consequential, incidental, special, exemplary, punitive, or indirect damages, including without limitation lost wages, lost profits, lost opportunities, emotional distress not tied to clinical negligence, or reputational harm, regardless of the legal theory or whether 24/7 DCT was advised of the possibility of such damages; (c) the limitations in this Section XV are essential elements of the bargain between the parties; the patient acknowledges that the fees charged by 24/7 DCT reflect this allocation of risk; and (d) any provision of this Section XV found unenforceable shall be modified to the minimum extent necessary while preserving the maximum protection afforded by law to 24/7 DCT.
XVI. INDEMNIFICATION BY PATIENT
I agree to indemnify, defend, and hold harmless 24/7 DCT, its affiliates, providers, employees, and agents from and against any and all claims, demands, actions, damages, losses, costs, expenses (including reasonable attorneys' fees and costs), fines, and penalties arising out of or related to: (a) my misrepresentation of identity, insurance coverage, eligibility, medical history, or any other information provided to 24/7 DCT, including any payor recoupment, audit, or investigation arising from such misrepresentation; (b) my misuse of any controlled medication or violation of any Controlled Medication Treatment Agreement; (c) my recording, capture, or distribution of any session, communication, or content from 24/7 DCT without prior written consent of the affected provider, including in violation of the Illinois Eavesdropping Statute (720 ILCS 5/14-2); (d) loss of confidentiality resulting from my own technology choices, environmental privacy failures, account credentials being shared, or third-party access to my devices; (e) my breach of this Agreement or any related document I have signed; (f) my conduct that violates the Patient Code of Conduct (Section V) or causes harm to 24/7 DCT personnel or property; and (g) any third-party claim arising from any of the foregoing. This indemnification obligation does NOT apply to claims arising from 24/7 DCT's own gross negligence, willful misconduct, or violation of law.
XVII. ARBITRATION AND CLASS ACTION WAIVER
EXCEPT for claims of medical malpractice, professional clinical negligence, or personal injury (which are NOT subject to this Section XVII and may proceed in court), all other disputes, claims, or controversies arising out of or relating to this Agreement, the services rendered, billing, fees, the parties' relationship, or any tort or statutory claim — including but not limited to claims for breach of contract, deceptive trade practices, debt collection, billing disputes, denial of service, breach of HIPAA or state confidentiality laws not constituting clinical negligence, defamation, breach of fiduciary duty in non-clinical contexts, and any claim for emotional distress not tied to clinical negligence — shall be resolved by FINAL AND BINDING ARBITRATION administered by the American Arbitration Association (AAA) under its Consumer Arbitration Rules, or, by mutual agreement, JAMS under its Streamlined Arbitration Rules. Arbitration shall be conducted in Cook County, Illinois, by a single arbitrator who is a licensed attorney with at least ten years of experience in healthcare law. Judgment on the award may be entered in any court of competent jurisdiction.
CLASS ACTION WAIVER. I AGREE THAT ALL CLAIMS SUBJECT TO ARBITRATION SHALL BE BROUGHT ON AN INDIVIDUAL BASIS ONLY. I WAIVE ANY RIGHT TO PARTICIPATE IN A CLASS ACTION, COLLECTIVE ACTION, REPRESENTATIVE ACTION, CONSOLIDATED ARBITRATION, OR PRIVATE ATTORNEY GENERAL ACTION AGAINST 24/7 DCT. The arbitrator may not consolidate more than one person's claims and may not preside over any form of representative or class proceeding. If any portion of this class-action waiver is found unenforceable, the entire arbitration agreement (other than this class-action waiver, which shall remain enforceable if severable) shall be null and void as to the unenforceable claims.
OPT-OUT RIGHT. I may opt out of this arbitration agreement (Section XVII) by delivering written notice of my decision to opt out to the 24/7 DCT Records Custodian within thirty (30) days of first signing this Agreement. The opt-out notice must contain my full name, address, and a clear statement that I wish to opt out of arbitration. Opting out of arbitration will not affect any other provision of this Agreement. If I do not opt out within 30 days, my agreement to arbitration is binding.
Mass Arbitration Procedures. If 25 or more substantially similar arbitration demands are filed against 24/7 DCT within a 60-day period (each, a "Coordinated Filing"), the parties agree that the following Mass Arbitration Procedures shall apply, notwithstanding any contrary provision of the AAA or JAMS Rules: (a) the demands shall be grouped into batches of no more than fifty (50) cases each; (b) the parties shall first select up to ten (10) bellwether cases (five chosen by each side) to proceed to arbitration on an individual, adjudicated basis; (c) following resolution of the bellwether cases, the parties shall engage in 90 days of good-faith mediation regarding the remaining cases, with a mediator jointly selected; (d) cases not resolved in mediation shall proceed in subsequent batches; (e) the parties may, by mutual agreement, modify these procedures to expedite resolution; and (f) the filing fees and case-management fees for the Coordinated Filing shall be allocated proportionally among the cases in each batch as the arbitrator(s) may determine. These Mass Arbitration Procedures are essential elements of the parties' agreement to arbitrate.
XVIII. JURY TRIAL WAIVER (Non-Arbitrable Claims)
FOR ANY CLAIM THAT IS NOT SUBJECT TO ARBITRATION UNDER SECTION XVII, INCLUDING ANY CLAIM FOR MEDICAL MALPRACTICE OR PROFESSIONAL CLINICAL NEGLIGENCE, THE PARTIES KNOWINGLY, VOLUNTARILY, AND INTENTIONALLY WAIVE THEIR RIGHT TO A TRIAL BY JURY. This waiver shall apply to any claim arising out of or relating to this Agreement, the services rendered, or the parties' relationship. The parties acknowledge that this waiver is a material inducement for entering into this Agreement.
XIX. LIMITATION OF ACTION
EXCEPT for claims of medical malpractice or professional clinical negligence, which are governed by 735 ILCS 5/13-212 and are not subject to this Section XIX, any claim or cause of action arising out of or related to this Agreement, the services rendered, billing, fees, or the parties' relationship must be filed (in arbitration or, where applicable, in court) within ONE (1) YEAR of the date the claim accrued. Failure to file within this one-year period shall be an absolute bar to the claim. The parties acknowledge that this contractual limitations period is reasonable, was knowingly negotiated, and is enforceable under Illinois law.
XX. PRE-LITIGATION NOTICE AND OPPORTUNITY TO CURE
EXCEPT for claims of medical malpractice or professional clinical negligence, no party may initiate litigation, arbitration, or other formal legal proceedings against the other party without first providing thirty (30) days' written notice describing in reasonable detail the nature of the claim, the specific provisions of this Agreement allegedly breached, and the relief sought, and providing the receiving party a reasonable opportunity to cure or respond. Notice to 24/7 DCT shall be sent to the Records Custodian at the address on file. This pre-litigation notice requirement does not apply where immediate equitable relief is necessary to prevent imminent and irreparable harm, but the noticed party still retains the right to cure for purposes of any subsequent damages claim.
XXI. NON-WAIVER
The failure of 24/7 DCT to enforce any right or provision of this Agreement, or to exercise any remedy available, shall not constitute a waiver of that right, provision, or remedy or of any other right, provision, or remedy. No waiver shall be effective unless in writing and signed by an authorized representative of 24/7 DCT.
XXII. PATIENT MISREPRESENTATION AND FRAUD
Any misrepresentation by the patient regarding identity, insurance coverage, eligibility, medical history, prior providers, dates of service, or any other material information shall constitute a material breach of this Agreement. Upon discovery of any such misrepresentation, 24/7 DCT shall be entitled, in its sole discretion, to: (a) immediately terminate the patient's services without further obligation (subject to 30-day continuity-of-care provisions set forth below); (b) recover all fees paid for services rendered, plus interest at the maximum rate permitted by law; (c) recover any payor recoupment, audit costs, fines, penalties, or other expenses arising from the misrepresentation; (d) refer the matter to law enforcement, regulatory authorities, and payors as the practice deems appropriate, including but not limited to referral for prosecution under 18 U.S.C. § 1347, § 1035, or any applicable Illinois healthcare-fraud statute; and (e) seek any other remedy available at law or equity. The patient indemnifies 24/7 DCT for all such amounts.
XXIII. TERMINATION RIGHTS
24/7 DCT may terminate this Agreement and the patient's services for cause, upon written notice, in any of the following circumstances: (a) violation of the Patient Code of Conduct (Section V); (b) any chargeback or payment dispute the practice deems unjustified; (c) any threat or attempted intimidation of any 24/7 DCT provider, employee, or agent; (d) non-compliance with the Controlled Medication Treatment Agreement; (e) any third-party legal action initiated against 24/7 DCT or any of its providers arising from the patient's care that the practice in good faith determines is unfounded; (f) misrepresentation as described in Section XXII; (g) failure to pay fees within 60 days of statement; (h) recording of sessions or communications without express written consent; or (i) any other material breach of this Agreement.
Upon termination, 24/7 DCT shall: (i) provide the patient with at least thirty (30) days of continuity-of-care coverage, including emergency-prescription bridge for any controlled medication where clinically appropriate and permitted by law; (ii) provide the patient with referral to alternative providers; and (iii) cooperate with any successor provider in the transfer of the patient's records, subject to applicable confidentiality and authorization requirements. These continuity obligations satisfy the practice's professional ethics obligations and shall not be construed as a waiver of the practice's termination rights.
XXIV. COOPERATION WITH AUDITS, PAYOR REVIEWS, AND INVESTIGATIONS
I agree to cooperate fully with any audit, claims review, utilization review, payment-integrity investigation, or other inquiry conducted by my insurance plan, Medicare, Medicaid, any HealthChoice Illinois MCO, or any other payor in connection with services rendered by 24/7 DCT. Cooperation includes, without limitation, providing accurate information, signing reasonable authorizations, attending interviews where reasonably required, and timely responding to payor requests. If I fail to cooperate with a payor audit or investigation, and the payor recoups payment, denies coverage, or assesses a penalty as a result of my non-cooperation, I shall be financially responsible for the recouped amount, denied charges, or penalty. This obligation supplements (and does not replace) the Cooperation provisions of any payor's subscriber agreement.
XXV. RECORDING PROHIBITION AND ILLINOIS EAVESDROPPING
I shall NOT record, capture, screenshot, screen-record, transcribe, or otherwise reproduce any session, telehealth visit, telephone call, or other communication with any 24/7 DCT provider, employee, or agent without the express prior written consent of the affected party. The Illinois Eavesdropping Statute (720 ILCS 5/14-2) makes the unauthorized recording of a private conversation a Class 4 felony. 24/7 DCT reserves all civil and criminal remedies available under Illinois law, including damages, injunctive relief, and referral for criminal prosecution. Any unauthorized recording shall constitute immediate grounds for termination of services and shall trigger the indemnification obligations in Section XVI.
XXVI. ONLINE REVIEWS — RESERVATION OF RIGHTS
I retain the right to publish truthful, honest reviews and opinions about 24/7 DCT and its services, and 24/7 DCT respects this right consistent with the federal Consumer Review Fairness Act (15 U.S.C. § 45b). However, I acknowledge that any review or public statement I make about 24/7 DCT must be truthful and not defamatory. 24/7 DCT reserves all rights, including but not limited to claims for defamation, defamation per se, false light, tortious interference with business relationships, and trade libel, against any party who publishes false or defamatory statements about 24/7 DCT, its providers, its employees, or its agents. Nothing in this Section XXVI prohibits truthful reviews or statements protected under federal or state law.
XXVII. INSURANCE VERIFICATION IS AN ESTIMATE ONLY
I acknowledge that any verification of insurance benefits performed by 24/7 DCT is an estimate based on information provided by the payor at the time of verification, and is not a guarantee of coverage or payment. The actual coverage determination is made by the payor after the claim is submitted, and may differ from any pre-service verification. Regardless of any pre-service verification or estimate, I am financially responsible for the actual amount owed for services rendered, including any amounts not covered by my payor.
XXVIII. RECORDS RELEASE — COSTS AND SUBPOENA RESPONSE
Records release fees set forth in Section VII apply to standard records requests. For subpoenas, court orders, depositions, trial testimony, or other legal-process responses, 24/7 DCT will charge the maximum amounts permitted by Illinois law, including without limitation: (a) hourly attorney rates for review and response; (b) document preparation, certification, and notarization fees; (c) statutory witness fees and mileage; (d) preparation, review, and deposition or trial testimony at the prevailing professional rate; and (e) any costs of asserting confidentiality protections, privileges, or shield-law rights on behalf of the patient or 24/7 DCT. These costs are payable by the requesting party in advance of production, except where state or federal law expressly prohibits charging the requestor. Indigent patients are entitled to one free copy of their records under 740 ILCS 110/4(b).
XXIX. FORCE MAJEURE
24/7 DCT shall not be liable for any failure or delay in performing its obligations under this Agreement to the extent caused by events beyond its reasonable control, including without limitation: pandemic, epidemic, or public-health emergency; natural disaster, fire, flood, severe weather, or earthquake; internet, telecommunications, or power outage; cyberattack, ransomware, or denial-of-service attack; governmental action, regulation, or order; civil unrest, war, terrorism, or labor dispute; any act of God; or any other force majeure event. In any such case, 24/7 DCT will use commercially reasonable efforts to resume services as soon as practicable and will work with affected patients to reschedule or accommodate alternative arrangements.
XXX. NO THIRD-PARTY BENEFICIARY
This Agreement is between 24/7 DCT and the patient (or the patient's parent, guardian, or authorized representative) only. No third party — including but not limited to family members, friends, romantic partners, employers, school personnel, attorneys, payors, or persons present during telehealth sessions — is a beneficiary of this Agreement, has any rights under this Agreement, or may bring any claim arising out of this Agreement.
XXXI. ASSIGNMENT
The patient may not assign, delegate, or transfer any rights or obligations under this Agreement without 24/7 DCT's prior written consent. 24/7 DCT may assign, delegate, or transfer this Agreement, in whole or in part, to any affiliate, successor in interest, or third party in connection with a sale, merger, acquisition, reorganization, or restructuring, without the patient's consent. This Agreement shall be binding on and inure to the benefit of the parties and their respective successors and permitted assigns.
XXXII. SEVERABILITY
If any provision of this Agreement is held invalid, illegal, or unenforceable by a court of competent jurisdiction or arbitrator, the remaining provisions shall remain in full force and effect, and the invalid provision shall be reformed to the minimum extent necessary to render it enforceable while preserving the parties' original intent. The invalidity of any provision shall not affect the validity of the remainder of the Agreement.
XXXIII. SURVIVAL
The following provisions shall survive any termination, expiration, or rescission of this Agreement: Section VII (Financial Policy and outstanding balances); Section IX (Privacy, Confidentiality, and Records — to the extent consistent with applicable law); Section XII (Record Retention); Section XV (Limitation of Liability); Section XVI (Indemnification); Section XVII (Arbitration); Section XVIII (Jury Trial Waiver); Section XIX (Limitation of Action); Section XX (Pre-Litigation Notice); Section XXII (Misrepresentation and Fraud); Section XXIV (Cooperation with Audits); Section XXV (Recording Prohibition); Section XXVI (Online Reviews); Section XXVIII (Records Release Costs); and any other provision that by its nature is intended to survive.
XXXIV. ENTIRE AGREEMENT AND NO ORAL MODIFICATIONS
This Agreement, together with the Notice of Privacy Practices, the Patient Bill of Rights, the Telehealth Informed Consent, the Assignment of Benefits, and any other documents executed by the patient at intake, constitutes the entire agreement between the parties and supersedes all prior or contemporaneous oral or written communications, proposals, agreements, and representations regarding its subject matter. No statement, representation, or promise made by any 24/7 DCT employee or agent — including representations regarding insurance coverage, scheduling, pricing, treatment outcomes, or any other matter — shall be binding unless reduced to writing and signed by an authorized representative of 24/7 DCT. This Agreement may not be modified except by a writing signed by an authorized representative of 24/7 DCT, provided that 24/7 DCT may unilaterally update its forms, policies, and procedures from time to time as set forth in Section XIII (Modification).
XXXV. COUNTERPARTS AND ELECTRONIC SIGNATURES
This Agreement may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one and the same Agreement. Electronic signatures, signatures captured through patient-portal click-through, signatures transmitted via email or fax, and signatures captured via secure electronic-signature platforms (e.g., DocuSign, Adobe Sign) are valid and binding to the same extent as original handwritten signatures, consistent with the federal Electronic Signatures in Global and National Commerce Act (15 U.S.C. § 7001) and the Illinois Uniform Electronic Transactions Act (815 ILCS 333/).