Consent For Treatment

Purpose: This form is intended to educate you and obtain your permission to participate in a telehealth consultation, e-Therapy session, or On-line counseling

Introduction: Telehealth utilizes interactive video conferencing, e-Therapy, On-line counseling as a method for delivering services. This enables the healthcare provider at a distant location to provide treatment to me and/or consult and advise my local healthcare provider in making decisions about the care provided to me. I understand that this consultation and form of receiving treatment will not be the same as a direct patient/health care visit due to the fact that I will not be in the same room as my provider. These alternative electronic methods of communication will allow me to receive care without the need to travel long distances to receive services.

During the telehealth consult, e-Therapy or On-line counseling session: a. Details of my medical history including but not limited to test results will be discussed with other professionals whom I have authorized. b. Non medical personnel may be present or involved to assist in operating video conferencing equipment. c. Only when I have provided written authorization, video, audio, and/or photo recordings may be taken during the procedure to aid in documenting the progress of my treatment.

Possible Risks: As with any behavioral health care procedure, there are potential risks associated with the use of telehealth, e-Therapy and On-line counseling. These risks include but may not be limited to: a. In certain cases, information may not be sufficient to allow for medical decision making b. Delays in evaluations or treatment progress could occur due to interruptions and/or failures of the equipment. c. Not withstanding best efforts to protect patient information, security protocols could fail, causing a breach of privacy of personal medical information.

Release of information: All existing laws regarding access to your medical information and copies of your medical records apply to this telehealth transmission. Additionally, dissemination of any patient-identifiable images or information from this telehealth interaction to researchers or other entities shall not occur without your consent.

Financial Responsibility: In consideration for the telehealth services rendered to me, I agree to pay the charges not covered by any third party payer, including deductible, co-payment, co-insurance, or any changes not covered as a result of my failure to provide notification or obtain pre-authorization for treatment as required by any insurer or third party payer. Should my account be referred for collection, I agree to pay reasonable attorney fees and collection expenses.

Disputes: I agree that any dispute arriving from the telehealth consult/exchange will be resolved in state where these services are being provided, and that that state’s law shall apply to all disputes.

Proxy: If I have signed this consent agreement on behalf of a person who may be temporarily or permanently incompetent, unable to sign, or a minor, I represent that I have the authority to sign this consent agreement on behalf of this person. This use of the first person in this consent agreement shall include me, and the person for whom I am representing. I have read and understand the information provided above regarding telehealth, have discussed it with my medical provider or behavioral health provider or such assistants as may be designated, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telehealth in my medical and behavioral health care.

 

    First Name (required)

    Last Name (required)

    Your Email (required)

    Today's Date (required)

    Your Date of Birth (required)

    Consulting Provider's Name (if applicable)

    Consulting Provider's Address (if applicable)

    I have read and understand the information provided above regarding telehealth, have discussed it with my medical provider or behavioral health provider or such assistants as may be designated, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telehealth in my medical and behavioral health care.

    I agree

    Your Full Legal Name (required)

    By entering my full legal name on this form, I understand that it is the equivalent to a signature on a physical document and will be treated as such.

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