Please read this document thoroughly and completely. If you have any questions, please contact me directly.
To better serve the needs of the community, mental health care services are now available by interactive video communications and/or by the electronic transmission of information. This process is referred to as “telehealth.” Telehealth involves the use of electronic communications to enable healthcare professionals (“Treatment Providers”) at different locations to provide mental health diagnostic, therapeutic or management services via real-time, interactive video conference for the purpose of increasing access and improving client care. The information may be used for healthcare delivery, diagnosis, treatment, transfer of medical data, therapy, consultation, follow-up and/or education.
Electronic systems used will incorporate network and software security protocols to protect the confidentiality of client identification and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption. Since this may be different than the type of consultation with which you are familiar, it is important that you understand and agree to the following statements.
1. Improved access to care by increasing access to specialty providers, especially in rural areas.
2. Decreased health care costs by reducing or eliminating the need to take time away from work, the cost of travel, and the cost of obtaining childcare.
3. Reduced stigma by allowing the client to receive care in a more convenient location.
4. Increased flexibility in the scheduling of appointments.
Although rare, there are potential risks associated with the use of telehealth. These risks include, but may not be limited to:
1. Information transmitted may not be sufficient (e.g. poor resolution of images, loss or reduction in physical cues, misinterpretation of communication) to allow for appropriate decision making by the Treatment Provider and consultant(s);
2. Delays in evaluation and treatment could occur due to technical deficiencies or failures;
3. The transmission of client’s medical information could be interrupted by unauthorized persons; and/or the electronic storage of my health care information could be accessed by unauthorized persons if the security protocols in place fail on either the clients or Treatment Provider’s end; and
4. A lack of access to complete health care records may result in adverse drug interactions or allergic reactions or other judgment errors.
Necessity of In-Person Evaluation:
If it becomes clear that the telehealth modality is unable to provide all pertinent clinical information during a particular telehealth encounter, the treatment Provider must make it known to the client prior to the conclusion of the live telehealth encounter. The Treatment Provider must also inform the client prior to the conclusion of the live telehealth encounter regarding the need for the client to obtain an additional in-person evaluation reasonably able to meet the client's needs.
By signing this form, I understand the following:
1. I understand that the laws that protect the privacy and the confidentiality of medical information also apply to telehealth. I understand that the information disclosed by me during the course of my treatment is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including but not limited to information demonstrating a probability of imminent physical injury to myself or others; immediate mental or emotional injury to myself; and where I make my mental or emotional state an issue in a legal proceeding. I also understand that the dissemination of any personally identifiable images or information from the telehealth interaction to researchers or other entities shall not occur without my consent.
2. 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.
3. I understand that I have the right to inspect all information obtained and recorded in the course of a telehealth interaction, and may receive copies of this information for a reasonable fee and under the supervision of the Treatment Provider.
4. 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 I may ask my Treatment Provider about alternative methods of care to telehealth.
5. I understand that telehealth may involve electronic communication of my personal medical information to other medical practitioners who may be located in independent contractors, to use telehealth in the course of my diagnosis and treatment.
6. I understand that it is my duty to inform my Treatment Provider of electronic interactions regarding my care that I may have with other healthcare providers.
7. I understand that telehealth-based services and care may not be as complete as face-to-face services. I also understand that if my TreatmentProvider believes I would be better served by another form of service (e.g. face-to-face services), I will be referred to a Treatment Provider who can provide such services in my area. Finally, I understand that there are potential risks and benefits associated with any form of treatment and that despite my efforts and the efforts of my Treatment Provider, my condition may not improve, and in some cases may even get worse.
8. I understand that I may expect the anticipated benefits from the use of telehealth in my care, but that no results can be guaranteed or assured.
9. I acknowledge that I have received a copy of my Treatment Provider’s contact information, including her or her name, telephone number, business address, and email address. I am aware that my Treatment Provider may contact the proper authorities in case of an emergency. I acknowledge, however, that if I am facing or if I think I may be facing an emergency situation that could result in harm to me or to another person, I am not to seek a telehealth consultation. Instead, I will seek care immediately through my own local health care provider or at the nearest hospital emergency department or by calling 911.
10. I understand that in the event of an adverse reaction to the treatment, or in the event of an inability to communicate as a result of technological or equipment failure, I shall seek follow-up care or assistance at the recommendation of my Treatment Provider.
In cases of emergency, use emergency services as well as our identified local support person.
If you have a concern or complaint about your treatment, please talk with me about it. I will take your criticism seriously and respond with care and respect. If you believe that I’ve been unwilling to listen and respond, or that I have behaved unethically, you can contact us or the Minnesota Board of Behavioral Health, Minnesota Board of Social Work, or Minnesota Board of Psychology. You may file a complaint with the appropriate board governing your therapist. We will not retaliate against you for filing a complaint.
Client Consent to The Use of Telehealth
I have read and understand the information provided above regarding telehealth and understand I have the opportunity to discuss it with my Treatment Provider. I hereby give my informed consent for the use of telehealth in my medical care.
Furthermore, I agree that the Released Parties have no liability or responsibility for the accuracy or completeness of the medical information submitted to them or for any errors in its electronic transmission.
I hereby authorize Family Connections Counseling Center, Inc., and its employees, agents, independent contractors, to use telehealth in the course of my diagnosis and treatment.