Tangible Wellness Informed Consent Form

How does telepractice work?

Telepractice means accessing intervention services through phone or internet-based telecommunications technology, as an alternative to in-person visits. Tangible Wellness offers telepractice dietetic services through the live interactive video conferencing software platforms Doxy.me or Colib. If telepractice is deemed appropriate for you then:

1.     The dietitian will set up a date and time for the session with the family and send a link, by email, to a secure online video conferencing service through either Doxy.me or Colib.

2.     Click the link to join the online waiting room.

3.     The dietitian will then admit the client to the meeting when services are ready to be provided.

4.     The family, client and dietitian interact through a secure live video feed. The dietitian interacts with the client and family to assess needs and collaboratively set goals for success. You will be provided with relevant and applicable resources via email during and/or after your appointment.

What does this service cost?

Intervention services delivered by telepractice (phone or videoconference) are billed at the dietitian’s established rate. This is consistent with general practices in medical and allied health fields. Please refer to pricing below or speak with the dietitian for details and length of appointments.

Will my third-party insurance cover telepractice?

It is your responsibility to contact your insurance provider to discuss details of your coverage for intervention services delivered by the dietitian via telepractice. We suggest you do this in advance of your appointment. We will provide you an invoice and a receipt for services.

What happens if there are technical difficulties during the session?

The dietitian will provide a number for you to call in the event of technical difficulties. The dietitian will work with you to attempt to resolve the problem. If it cannot be resolved, the session fee will be prorated for the duration of the therapy appointment completed and the remainder of the appointment time will be rescheduled.

What is the cancellation policy?

Tangible Wellness has a regular cancellation policy that applies to visits delivered by telepractice. Sessions must be rescheduled or cancelled at least 24 hours in advance or they will be charged at the full rate. Clients with repeated last minute cancellations will no longer be offered telepractice services.

I understand the following:

·      I understand that “telepractice” includes assessment and goal-setting using interactive audio, video, or data communications. I understand that telepractice also involves the communication of my medical information, both orally and visually.

·      I understand that I am responsible for providing the necessary computer, telecommunications equipment (camera and microphone) and internet access for my telepractice sessions. 

·      I understand that all assessments and interventions are one-on-one with the parent/caregiver or the child as needed, and that other children will not be allowed in the session. Up to 2 parents/caregivers will be allowed to participate as needed.

·      I understand that all nutrition packages purchased from Tangible Wellness expire after 6 months and fees for missed appointments will not be reimbursed.

·      I understand the risks and benefits of corresponding via email with my Registered Dietitian and give my informed consent to use this method of communication.

·      I understand that all letters and forms required by third parties (insurance, schools, etc.) are not included in the price of the assessment and will be billed at clinic rates.

·      I understand that healthcare information may be shared with other individuals in the health care team for the purposes of scheduling, billing, and in implementing a patient’s plan of care and that these individuals involved will at all times maintain confidentiality of the information obtained and the laws that protect privacy and confidentiality of medical information equally apply to telepractice.

·      I will pay for my telepractice session at least 24 hours in advance. If I do not pay 24 hours in advance, I understand that my session will be cancelled or rescheduled. I understand that sessions cancelled with less than 24 hours notice will be billed at the dietitian’s regular rate.

·      I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment.

·      The laws that protect the confidentiality of my medical information also apply to telepractice. As such, I understand that the information disclosed by me during my session or consultation is confidential.

·      I understand that Tangible Wellness does not submit any documents to my insurance directly or guarantee my reimbursement by insurance companies. I am responsible for contacting my insurer prior to the session to ensure my own eligibility. I understand there are no refunds for telepractice sessions.

·      I understand that there are risks and consequences from email and teletherapy, including, but not limited to, the possibility, despite reasonable efforts on the part of Tangible Wellness, that: the transmission of my information could be disrupted or distorted by technical failures; the transmission of my information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons.

I have read this document carefully, and understand the risks, benefits, and my rights related to the telepractice and I am hereby electively giving my informed consent to participate in a telepractice service through Tangible Wellness under the terms described herein. 

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Email *
Child/Client Full Name *
Parent/Guardian Full Name
Date
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I have read and understood the terms and conditions and give my consent to participate in telepractice nutrition counselling. *
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