Introduction of Telebehavioral Health

As a client receiving Telebehavioral Health Services (TBH), I understand:

• TBH is the delivery of behavioral health services using interactive technologies between a practitioner and a client who are not in the same physical location.
• The interactive technologies used in TBH incorporate network and software security protocols to protect the confidentiality of client information by using a secure, HIPAA/HITECH compliant network.
• The service is provided by technology including, but not limited to, computers with built in or external cameras and microphones; tablets and smartphones, and may not involve face to face communication.
• During my TBH services, details of my medial history and personal health information may be discussed with myself and my behavioral health care professional through the use of interactive video, audio, or other telecommunications technology.

Benefits and Risks of TBH

• There are benefits to this service as follows:
• Services may be performed remotely.
• It allows me to receive services if I do not wish to or are unable to come in to the office.
• It allows access to services from outside the local geographic area and in all parts of Ohio.
• Services may be received from the convenience of my home.

There are risks to the service as follows:

• Although the data is transferred across a secure, HIPAA/HITECH encrypted network, there could be a possibility that my personal information may be breached by unauthorized persons and my confidential information may be intercepted.
• There may be a disruption of service due to technological difficulties.
• Some of the information my practitioner would ordinarily get in person to person consultation may not be available in TBH.  I understand in some situations such missing information could make it more difficult for my practitioner to understand my problems.
• My practitioner will be unable to provide in person emergency services.
• I realize that it is my responsibility to ensure I am in a private location free of distraction when I am receiving TBH services, and no responsibility for my location or for my privacy while receiving services lies with my provider.

Limits of Confidentiality

• I understand that, under the law, if I share information that leads my telehealth practitioner to believe I am a danger to self or others, or if I disclose knowledge of child abuse, my practitioner is required to take action to intervene, including contacting appropriate authorities.

 

Informed Consent for Telebehavioral Health Service

Electronic Presence

• I understand that my practitioner will not be physically in my presence.  Instead, we will see and hear each other electronically, and information will pass electronically between me and my practitioner.

Emergency Care

• I acknowledge that if I am facing or if I think I am facing an emergency situation that could result in harm to me or another person, I am not to seek a Telebehavioral health consultation.  Instead, I agree to seek care immediately through my own local healthcare provider or at the nearest hospital emergency room, or by calling 911.

Modification and Termination

• My practitioner and I will regularly review and assess the appropriateness of continuing to deliver services to me through the use of Telebehavioral Health.
• I may decline TBH services at any time without jeopardizing my access to future care, services, and benefits.
• I may receive a combination of TBH and in person services if I so desire.

Final Agreement

1. I HAVE READ THIS DOCUMENT CAREFULLY AND FULLY UNDERSTAND THE BENEFITS AND RISKS OF THIS SERVICE.  I HAVE HAD THE OPPORTUNITY TO ASK QUESTIONS AND I HAVE RECEIVED SATISFACTORY ANSWERS.
2. WITH THIS KNOWLEDGE, I VOLUNTARILY CONSENT TO PARTICIPATE IN TELEBEHAVIORAL HEALTH SERVICES, INCLUDING BUT NOT LIMITED TO ANY ASSESSMENT, TREATMENT, CONSULTATION OR OTHER SERVICES DEEMED NECESSARY BY MY PROVIDER.