Hope419 Virtual Consent Form
Introduction

Hope419 Virtual visits are a form of telemedicine that allows patients to access psychiatric care using audio-video interface such as videoconferencing.

Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

Expected Benefits:

Improved access to psychiatric care by enabling a patient to remain in his/her home or office.
More efficient psychiatric evaluation and management.
Obtaining expertise of a distant specialist.

Possible Risks:

As with any medical procedure, there are potential risks associated with the use of virtual visits. These risks include, but may not be limited to:

In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the physician and consultant(s);
Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment;
In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information;
In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgmental errors.
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Email *
By signing this form, I understand the following:

I understand that the laws that protect privacy and the confidentiality of medical information also apply to virtual visits, and that no information obtained in the use of virtual visits which identifies me will be disclosed to researchers or other entities without my consent.

I understand that I have the right to withhold or withdraw my consent to the use of virtual visits in the course of my care at any time, without affecting my right to future care or treatment.

I understand that I have the right to inspect all information obtained in the course of a virtual visit, and may receive copies of this information for a reasonable fee.

I understand that a variety of alternative methods of mental health care may be available to me, and that I may choose one or more of these at any time.

I understand that it is my duty to inform my psychiatrist and or therapist of any other healthcare providers involved in my medical/psychiatric care.

I understand that I may expect the anticipated benefits from the use of virtual visits in my care, but that no results can be guaranteed or assured.

** I understand that to be able to participate in a virtual appointment with my provider I MUST BE IN THE STATE OF OHIO based on state to state regulations and laws. 
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I have read and understand the information provided above regarding virtual visits, have discussed it with my clinician, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of virtual visits in my care through Hope419. *
Patient First and Last Name *
Patient Date of Birth *
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CLIENT SIGNATURE - By typing your name below, you certify that you understand the risks and limitations to online mental health treatment. (Please type the full legal name of the person completing this form. By doing so, you agree that your typed signature has the same validity and meaning as your handwritten signature.) *
If you are in crisis please review or contact the following:
https://suicidepreventionlifeline.org/current-events/the-lifeline-and-988/

Dial 988

Dial 1-800-273-8255
A copy of your responses will be emailed to the address you provided.
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