I hereby authorize the use of telemedicine services and/or video conferencing in the course of my treatment. I understand that telemedicine services and/or video conferencing involve the communication of my medical information both orally and/or visually.
I understand I have all the following rights with respect to telemedicine services and/or video conferencing:
Client Choice of Care. I have the right to withhold or withdraw my consent at any time (not retroactively) and will do so in writing. This will not affect my right to future treatment.
Access to Information. I have the right to inspect all medical information that includes the telemedicine service and/or video conferencing visit. I may obtain copies of this medical record information for a reasonable fee.
Confidentiality. I understand that the laws which protect the confidentiality of medical information apply to telemedicine services and/or video conferencing. My visit will not be recorded and all identifying information in the interaction will be kept secure in the same manner as any other private medical information.
Potential Risks. I understand that there are risks from telemedicine service and/or video conferencing. These risks include, but are not limited to, the possibility (despite our best efforts to prevent this) that the transmission of medical information could be disrupted or distorted by technical failures in transmission.
I also understand that the electronic transmission of medical information could be interrupted or even accessed illegally by unauthorized persons.
Benefits. I understand that I can expect benefits from telemedicine services and/or video conferencing, but that no results can be guaranteed or assured. Telemedicine or video conferencing provides me with access to mental health care that otherwise would not have been available in my community.