HOST – SAMHSA Youth Support Program
This form will be used to provide Bridgeway Rehabilitation Services with basic information about an individual that you are referring to be evaluated. It does not constitute a contract or a commitment for services for the individual.
References to any entity, product, service or source of information not related to Bridgeway and GoMo Health should not be considered an endorsement, either direct or implied, by Bridgeway or GoMo Health. Bridgeway and GoMo Health do not recommend or endorse any specific tests, products, procedures, opinions or other information that may be provided on any linked websites. The linked websites may contain text, graphics, images or information that you find offensive. Bridgeway and GoMo Health have no control over and accept no responsibility for such materials.
GoMo Alerts sends standard emails. Beyond the individual’s name, no other information about the individual is included in the email. Any information about the nature of an individual’s condition is in a secure, password-protected database. Bridgeway Rehabilitation Services and GoMo Health will not send Protected Health Information (PHI) via text or email as part of this program. Protected Health Information (PHI) will be used and disclosed in accordance with HIPAA and applicable privacy laws.
GoMo Health does not sell, trade or rent personal information to other companies or individuals. GoMo Health uses industry-leading Secure Sockets Layer (SSL) technology to keep personal information as secure as possible. Participant information will only be used for its intended purpose.
GoMo Health and Bridgeway may use information collected through its services for research and development purposes. However, such usage will not include any personally identifiable information in such research or development. Personal information collected is stored in our secure cloud-based database, and we reserve the right to divulge information only as mandated to comply with state and federal laws.
GoMo Health aggregates the participant information voluntarily submitted to this program, to improve the program performance. GoMo Health may also receive Personal Health Information about participant health from Bridgeway. GoMo Health may also aggregate the information from the two sources listed above.
Text and E-mail
When a participant sends a text message and/or email with program-specific data, their mobile phone number and/or e-mail address, the full content of the message, attached files, or other information provided may be recorded. The program may use this information to determine and send appropriate information or educational content to participants. Participants may indicate their preference to stop receiving communications or opt-out at any time. (See Your Choices Regarding Your Personal Information).
Information Collected Via Technology
Use and Disclosure of Information
In general, Personal Health Information and other information submitted and/or shared with the program may be used for the following purposes: to enable participant access to program services; to personalize the content received by the program; and/or to provide additional information and functionality upon request.
We may, when required, provide Personal Health Information to third-party service providers or affiliates who work on our behalf, to provide some of the services features necessary to help us communicate with participants. Examples of such services include sending texts or e-mails, analyzing data and providing customer service. Participant information provided under a Business Associate Agreement to the aforementioned affiliates and third-party service providers are not to be utilized in any manner except as necessary to provide the relevant program services. If you are not willing to allow the program to use or disclose your collected Personal Health Information as identified above, you may choose to not participate in the program.
The program uses Google Analytics to analyze how visitors interact with the program web site. This service provides non-personally identifiable data including but not limited to data on where visitors came from, what actions they took on our site and where visitors went when they left our site.
The program may disclose Personal Health Information if necessary to comply with relevant laws or to respond to subpoenas or warrants served on us. You hereby consent to us sharing your Personal Health Information under the circumstances described herein.
PROHIBITED USES OF THE PLATFORM
You shall not transmit, redistribute, or promote any communications, content, or materials that (a) contain corrupted files, viruses, or any other similar software files, the intent of which is to damage the operation of another’s computer; (b) are unlawful, threatening, harassing, abusive, defamatory, invasive of privacy or publicity rights, obscene, or otherwise objectionable; (c) infringes, misappropriates, or violates the intellectual property rights or other rights of any third party; (d) impersonate any person, business, or entity, including our company, employees, or agents; (e) violate any law (including, but not limited to, HIPAA); or (f) amounts to any conduct that, in our judgment, restricts, impairs, interferes, or inhibits any other user from using or enjoying, or is otherwise detrimental to, the Platform. You shall not: (g) use automated means, including spiders, robots, crawlers, data mining tools, or the like to download data from the Platform; (h) cover, obscure, block, or in any way interfere with any advertisements and/or safety features (e.g., report abuse button) on the Platform; or (i) access or use the Platform to collect any market research for a competing business.
DISCLAIMER AND LIMITATION OF LIABILITY
THE CONTENT PROVIDED ON THE PLATFORM AND IN ANY OTHER COMMUNICATIONS FROM, OR PROVIDED THROUGH, THE PLATFORM IS NOT INTENDED AS A SUBSTITUTE FOR, NOR DOES IT REPLACE, PROFESSIONAL MEDICAL ADVICE, DIAGNOSIS, OR TREATMENT. GOMO HEALTH MAKES NO REPRESENTATIONS OR WARRANTIES, WHETHER EXPRESSED OR IMPLIED, WITH RESPECT TO THE ACCURACY AND COMPLETENESS OF THE CONTENT AS IT RELATES TO YOUR MEDICAL HISTORY OR MEDICAL RECORDS.
YOU ACKNOWLEDGE THAT THE PLATFORM MAY CONTAIN BUGS, ERRORS, AND OTHER PROBLEMS THAT COULD CAUSE SYSTEM FAILURES. CONSEQUENTLY, THE PLATFORM AND THE CONTENT ARE PROVIDED “AS IS” AND “AS AVAILABLE” WITHOUT ANY WARRANTIES OF ANY KIND, INCLUDING THAT THE PLATFORM OR CONTENT WILL OPERATE ERROR-FREE OR THAT THE PLATFORM, ITS SERVERS, OR THE CONTENT ARE FREE OF COMPUTER VIRUSES OR SIMILAR CONTAMINATION OR DESTRUCTIVE FEATURES.
GOMO HEALTH AND BRIDGEWAY DISCLAIM ALL WARRANTIES, INCLUDING, BUT NOT LIMITED TO, WARRANTIES OF TITLE, MERCHANTABILITY, NON-INFRINGEMENT OF THIRD PARTIES’ RIGHTS, AND FITNESS FOR PARTICULAR PURPOSE AND ANY WARRANTIES ARISING FROM A COURSE OF DEALING, COURSE OF PERFORMANCE, OR USAGE OF TRADE.
IN CONNECTION WITH ANY WARRANTY, CONTRACT, OR COMMON LAW TORT CLAIMS: (I) GOMO AND BRIDGEWAY SHALL NOT BE LIABLE FOR ANY INCIDENTAL OR CONSEQUENTIAL DAMAGES, LOST PROFITS, OR DAMAGES RESULTING FROM LOST DATA OR BUSINESS INTERRUPTION RESULTING FROM THE USE OR INABILITY TO ACCESS AND USE THE PLATFORM OR THE CONTENT, EVEN IF WE HAVE BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGES; AND (II) ANY DIRECT DAMAGES THAT YOU MAY SUFFER AS A RESULT OF YOUR USE OF THE PLATFORM OR THE CONTENT SHALL BE LIMITED TO FIFTY UNITED STATES DOLLARS (US$50).
SOME JURISDICTIONS DO NOT ALLOW THE EXCLUSION OF CERTAIN WARRANTIES. THEREFORE, SOME OF THE ABOVE LIMITATIONS ON WARRANTIES IN THIS SECTION MAY NOT APPLY TO YOU.
We reserve the right, in our sole discretion, to restrict, suspend, or terminate your access to all or any part of the Platform, at any time and for any reason without prior notice or liability. We reserve the right to change, suspend, or discontinue all or any part of the Platform at any time without prior notice or liability.
Your Choices Regarding Your Personal Information
This program offers choices to participants regarding the collection, use, and sharing of their Personal Health Information. Participants have a right at any time to unsubscribe and discontinue program contact by replying “STOP” at any time after receiving a text message. Participants may contact GoMo Health directly, via email, at firstname.lastname@example.org.