I hereby consent to telehealth services as part of my care. I understand that telehealth is the practice of delivering Counseling/Advocacy services via technology assisted media or other electronic means between a practitioner and a client who are located in two different locations.
I understand that telehealth is the practice of delivering Counseling/Advocacy services via technology assisted media or other electronic means between a practitioner and a client who are located in two different locations.
I understand the following with respect to telehealth:
1) I understand that I have the right to withdraw consent at any time without affecting my right to future care, services, or program benefits to which I would otherwise be entitled.
2) I understand that there are risk and consequences associated with telehealth, including but not limited to, disruption of transmission by technology failures, interruption and/or breaches of confidentiality by unauthorized persons, and/or limited ability to respond to emergencies. I understand that the care provider or I can discontinue the telehealth encounter if it is felt that the videoconferencing connections are not private or adequate for the situation.
3) I understand that there will be no recording of any of the online sessions by either party. All information disclosed within sessions and written records pertaining to those sessions are confidential and may not be disclosed to anyone without written authorization, except where the disclosure is permitted and/or required by law.
4) I understand that the privacy laws that protect the confidentiality of my protected health information (PHI) also apply to telehealth unless an exception to confidentiality applies (i.e. mandatory reporting of child, elder, or vulnerable adult abuse; danger to self or others).
5) To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment.
6) Telehealth is NOT an Emergency Service and in the event of an emergency, I will call 911. I understand that if I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms or experiencing a mental health crisis that cannot be resolved remotely, it may be determined that telehealth services are not appropriate and a higher level of care is required.
7) I understand that during a telehealth session, we could encounter technical difficulties resulting in service interruptions. If this occurs, we will end and restart the session. If we are unable to reconnect within ten minutes, I will call my provider at the direct number they have provided to me to determine next steps. If our scheduled session time concludes before I am able to reach my provider, I will leave a message.
8) I understand that telehealth may utilize my personal cellular data if I am on a cell phone or other device which uses cellular data. I take responsibility for ensuring the security of that connection and I am responsible for ensuring I have sufficient data to support a telehealth session prior to my session. Ampersand is not responsible for any costs associated with the use of phone service or data.