Telehealth Services Informed Consent

Definition of Telehealth
Telehealth involves the use of electronic communications to enable professionals to connect with individuals using interactive video and audio communications. Telehealth includes the practice of psychological health care delivery, diagnosis, consultation, treatment, referral to resources, education, and the transfer of medical and clinical data.

I understand that I have the rights with respect to telehealth:

1. I understand that the same standard of care applies to a telemedicine visit as applies to an in-person visit
2. I understand privacy and the confidentiality laws apply to telehealth, and that no information obtained through the use of telehealth services will be disclosed to researchers or other entities without my written consent.
3. My health care provider has explained how the videoconferencing technology will be used to conduct a telehealth session, that unlike a direct patient/provider in person, I will not be in the same room as my health care provider.
4. I understand the potential risks to technology including interruptions, unauthorized access and technical difficulties. I understand my health care Provider or I can discontinue the videoconference consult/visit if it is believed videoconferencing technologies are not adequate for the situation.
5. I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment.
6. I understand that telehealth may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.
7. I understand that no results for anticipated benefits can be guaranteed or assured by my provider.
8. I understand my healthcare information may be shared with other individuals for purposes of scheduling and billing. Individuals other than my healthcare provider may be present during the session in order to operate videoconferencing equipment. I further understand that I will be informed of their presence, and that such individuals will maintain confidentiality on information obtained during the session. Furthermore, I have the right to request the following:
   • ask non-medical personnel to leave the telehealth examination room; and/or
   • terminate the consultation at any time.
9. I agree certain situations — such as emergencies and crisis — are inappropriate for audio-/video-/computer- based psychotherapy services. If I am in crisis or in an emergency, I should immediately call 911 or seek help from a hospital or crisis-oriented healthcare facility in my immediate area.
10. I understand that should I elect to submit a claim for coverage of these services to my insurance carrier, my insurance carrier will have access to my medical records for quality review/audit. I understand that I will be responsible for any out-of-pocket costs such as copayments or coinsurances that apply to my telemedicine visit. I understand that health plan payment policies for telemedicine visits may be different from policies for in-person visits.
11. I understand that this document will become a part of my medical record.

Consent to The Use of Telehealth
By signing this form, I certify:

• That I have read or had this form read and/or had this form explained to me.
• That I fully understand its contents including the risks and benefits of the procedure(s).
• That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.