This document contains important information about our decision (yours and mine) to resume in-person services in light of the COVID-19 public health crisis. Please read this carefully and let me know if you have any questions. When you sign this document, it will be an official agreement between us.
Decision to Meet Face-to-Face
We have agreed to meet in person for some or all future sessions. If there is a resurgence of the pandemic or if other health concerns arise, however, I may require that we meet via telehealth. If you have concerns about meeting through telehealth, we will talk about it first and try to address any issues. You understand that, if I believe it is necessary, I may determine that we return to telehealth for everyone’s well-being.
If you decide at any time that you would feel safer staying with, or returning to, telehealth services, I will respect that decision, as long as it is feasible and clinically appropriate. Reimbursement for telehealth services, however, is also determined by the insurance companies and applicable law, so that is an issue we may also need to discuss.
Risks of Opting for In-Person Services
You understand that by coming to the office, you are assuming the risk of exposure to the coronavirus (or other public health risk). This risk may increase if you travel by public transportation, cab, or ridesharing service.
Your Responsibility to Minimize Your Exposure
To obtain services in person, you agree to take certain precautions which will help keep everyone (you, me, and our families, our staff, and other patients) safer from exposure, sickness and possible death. If you do not adhere to these safeguards, it may result in our starting / returning to a telehealth arrangement. Your electronic signature below indicates that you understand and agree to these actions:
You will only keep your in-person appointment if you are symptom free or discuss your symptoms with your provider.
If your temperature is elevated (100 Fahrenheit or more), or if you have other symptoms of the coronavirus or flu, you agree to cancel the appointment or proceed using telehealth.
You will wait in your car or outside until our appointment time.
You will wash your hands or use alcohol-based hand sanitizer when you enter the building.
If you are bringing your child, you will make sure that your child follows all of these sanitation and distancing protocols.
You will take steps between appointments to minimize your exposure to COVID.
If you have an exposure to Covid-19 or someone in your home tests positive, you will immediately let me know and we will meet via telehealth.
·I may change the above precautions if additional local, state or federal orders or guidelines are published. If that happens, we will talk about any necessary changes.
If You or I Are Sick
You understand that I am committed to keeping you, me, our staff, and all of our families safe from the spread of this virus. If you or a family member whom you live with are exhibiting symptoms of non-allergy illness, we ask you to stay home, take care of yourself, and seek medical help when appropriate. Please do not come in for office visits until you have been symptom free (or your family member is symptom free) for 5 days (or current CDC guidelines). Contact your therapist to cancel and reschedule your appt. If you are well enough for a virtual visit, you may ask your therapist to move your session to a virtual platform to continue services.
If I or our staff test positive for the coronavirus, I will notify you so that you can take appropriate precautions.
Your Confidentiality in the Case of Infection
If you have tested positive for the coronavirus, I may be required to notify local health authorities that you have been in the office. If I have to report this, I will only provide the minimum information necessary for their data collection and will not go into any details about the reason(s) for our visits. By signing this form, you are agreeing that I may do so without an additional signed release.
