Psychiatric Telehealth Consent

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Email *

Name *

Date of birth *

YYYY

1. Purpose: The purpose of this form is to obtain your consent to participate in telehealth for the following service(s): *

2. Telehealth in General: Telehealth involves the real-time evaluation, diagnosis, consultation on, and treatment of a health care condition using advanced telecommunications technology, including interactive audio & video. Electronic systems used have network and software security protocols in place to protect the confidentiality of patients’ information. *

I understand the above.

3. Expected Benefits: Center for Therapy & Counseling Services ("The Center"), offers telehealth services to its patients in order to improve access to health care by enabling a patient to remain at home (or at a remote site) while receiving care from a distance. *

I understand the above.

4. POTENTIAL RISKS:

> In the event of interruption or disconnection of the audio/video connection, the continuity or completion of a particular telehealth visit will depend upon whether the information transmitted is sufficient for the patient’s condition. *

I understand the above.

> Your health information will be transmitted electronically by audio and video. In accordance with HIPAA regulations, The Center has implemented strict privacy and security precautions to protect its patients’ health information; however, the security and confidentiality of information transmitted electronically may be compromised by the failure of these security safeguards or illegal or improper tampering. *

I understand the above.

> While The Center has taken reasonable and appropriate efforts to eliminate any confidentiality risks associated with your telehealth appointment, The Center cannot control your environment or any company you may have with you during the telehealth appointment. *

I understand the above.

5. NATURE OF TELEHEATH

> During the telehealth appointment, details of your medical history and current condition may be discussed by interactive audio-video technology. The Center and its providers rely on information provided by you and it is your responsibility to provide information about your medical history, condition, and care that is complete and accurate to the best of your ability. The Center and its providers’ advice, recommendations, and decisions may be based on factors not within their control, such as incomplete or inaccurate data provided by you or distortions of audio/video during the telehealth visit. *

I understand the above.

> The Center has the right to determine if a telehealth appointment is appropriate for your needs and may recommend an in-person appointment or alternate treatment options. *

I understand the above.

6. Medical Records: All existing State and federal laws regarding the privacy and security of your medical records apply to this telehealth appointment, as detailed in The Center's Notice of Privacy Practices. In accordance with HIPAA, The Center will not record or store any video, images, or audio of your telehealth appointment, and by signing below you agree not to record or store any video, images, or audio of your telehealth appointment. Your provider will document the medical information conveyed during the appointment into your medical record the same as if it was an in-person office visit. You have the right to obtain copies of your medical records; any requests to inspect and obtain copies of medical records associated with telehealth will be made in accordance with Thr Center's standard policies and procedures. *

I understand the above.

7. Payment Agreement. By signing below, you understand that you are responsible for the full fees for telehealth psychiatric services you receive from The Center. If you have any questions about your billing, you should contact The Center's office. *

I understand the above.

8. Data and Devices. The Center does not warrant that its telehealth services will be compatible with any updates to, or prior versions of, your devices’ operating systems. To the extent that your telehealth appointment requires the use of wireless, cellular data, or internet access, you are responsible for securing the necessary data access service. E.g., your mobile phone provider may charge you data access fees in connection with your use of telehealth services. You are solely responsible for all such charges payable to third parties. *

I understand the above.

9. Patient Rights: You may withhold or withdraw your consent to telehealth at any time without affecting your right to future care or treatment. You may contact The Center at (732) 254-0600 for any questions you have related to telehealth services. *

I understand the above.

10. Risks, Consequences, and Benefits: By signing below, you acknowledge that: (i) you have been advised of the potential risks, consequences, and benefits of telehealth; (ii) you have had an opportunity to ask questions about the information presented on this form; and (iii) all your questions have been answered and you understand the information provided above. *

I understand the above.

Typing my name below (or other written acknowledgement of my acceptance to the terms above) indicates my consent to participate in a telehealth appointment in connection with the service(s) described above. This consent will be documented in my medical record with The Center. *

Date *

YYYY

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