Effective Date: September 19, 2025
Entity: Marula LLC, Administrative Office, Pleasant Grove, Utah
Applies
To: All patients receiving telehealth services administered through Marula Rehab
1. Purpose of Consent
By signing or electronically accepting this Consent, you agree to receive behavioral health services via telehealth from licensed providers affiliated with Marula Rehab. Telehealth involves the use of secure video conferencing, electronic communications, and remote data exchange to deliver care.
2. Nature of Telehealth Services
Telehealth services may include:
Intake assessments and diagnostic evaluations
Educational instruction and relapse recovery support
Substance use disorder and alcohol dependency treatment
Referrals for Medication-Assisted Treatment (MAT) when appropriate
You understand that services are provided remotely and that your provider may not be physically located in your state.
3. Privacy & Security
Marula LLC complies with the Health Insurance Portability and Accountability Act (HIPAA). All Protected Health Information (PHI) is:
Encrypted using TLS 1.3 during transmission
Stored on HIPAA-compliant servers located in the United States
Accessible only to authorized personnel
Protected by multi-factor authentication and audit logging
You acknowledge that while Marula LLC takes all reasonable precautions, no system is 100% secure, and risks of unauthorized access may exist.
4. Licensure & Geographic Limitations
You confirm that you are physically located in a jurisdiction where Marula Rehab’s providers are licensed to practice. Services may be denied or discontinued if you relocate to a non-covered state.
5. Limitations of Telehealth
You understand that:
Telehealth may not be appropriate for all conditions
There may be limitations in physical examination and emergency response
You are responsible for seeking in-person care if advised or needed
Marula LLC does not provide emergency services. If you are experiencing a crisis, call 911 or go to the nearest emergency room.
6. Voluntary Participation & Withdrawal
Your participation in telehealth is voluntary. You may withdraw consent at any time by notifying Marula LLC in writing or discontinuing use of the service. Withdrawal will not affect your right to future care or Medicaid benefits.
7. Financial Disclosure
You understand that:
Marula LLC offers a sliding scale fee structure
Medicaid enrollment assistance may be available
You are responsible for any applicable copays or fees disclosed during intake
8. Contact for Questions
If you have questions about this Consent or your rights:
Email: info@marulallc.com
Phone: 1-801-427-5515
Address: 2728 N. Canyon Road, Pleasant Grove, Utah 84062
Patient Acknowledgment
By Submitting your Registraton and Other reqiuired docments and beginning treatment with Marla LLC, you are acknowledging that you accept this Concent to Telehealth Treatment provided by Marula LLC as if you have affixed your true signature to this docuent:--and--
You confirm that:
a. You have read and understood this Consent
b. You agree to receive telehealth services from Marula Rehab
c. You understand the risks, benefits, and limitations of telehealth
d. You have had the opportunity to ask questions
This Document is also included in your intake and onboarding package that will be associated with your submission of your State ID or Issued Valid Driver License.