Telehealth - Consent for Treatment

ACKNOWLEDGEMENT AND UNDERSTANDING OF GENERAL INFORMATION *

I have read and acknowledged general information about Telehealth, including benefits and risks: Telehealth involves the use of interactive 2-way video and audio communication (also know as Telemedicine) to conduct a “virtual office visit,” as well as transmission of still images. The information provided over telemedicine may be used for diagnosis, therapy, follow-up, and education. Electronic systems used for Telehealth incorporate reasonable network and software security protocols and encryption to protect the confidentiality of Protected Health Information and include measures to safeguard the data and to ensure the integrity against intentional or unintentional corruption consistent with the Health Insurance Portability and Accountability Act (HIPPA). Potential benefits include: improved access to convenient medical care, more efficient medical evaluation and management, obtaining the expertise of a distant specialist and continuous continuity of care. Possible Risks include, but may not be limited to: in rare cases, information transmitted may not be enough (e.g. poor resolution of images) to allow for appropriate medical decision making by h physician and consultant(s), delays in medial evaluation and treatment could occur due to deficiencies or failure of the equipment. In very rare instances, security protocols could fail, causing a breach of privacy or personal medical information. In rare cases, a local of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgments errors. Special risks associated with home computers include Plymouth Psych Group's inability to control the security of the computer you choose to use for Telehealth communications or the location where you choose to use it. Even through a platform is secured over the internet Viruses, Malware, Spyware, and other programs can be installed on the computer itself without a user’s knowledge and could be used to record the audio and video of a Telehealth sessions without your knowledge. Unencrypted or poorly encrypted wireless networks could also allow someone to intercept the audio and video being transmitted over the network. Plymouth Psych Group therefore recommends that you only use a privately owned personal computer with up to date antivirus software in a room of your own home that is conversationally private. You assume all risks of your telemedicine session being recorded, seen and/or heard by unauthorized persons.

Patient Name: *

First Name Last Name

Date of Birth: *

Date

Location of Patient *

(home, office, etc.)

Name of Clinician *

PATIENT CONSENT TO USE OF TELEHEALTH *

I hereby authorize the clinician as named below to use Telehealth in the course of my assessment, diagnosis, and/or treatment. By signing this form, I agree that I am willing to undertake the risks associated with Telehealth in order to take advantage of the convenience it offers. I understand that I can revoke my consent to Telehealth at any time without affecting my rights to future care or treatment, as long as I agree to travel to my provider’s off to meet them in person. I have read and understand the information provided above regarding Telehealth, have discussed it with my 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 care.

Name of Clinician *

Patient Signature *

Clear

Date

Parent/Guardian Signature (if 16 or younger)

Clear

Date

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