I hereby consent to engage in telemedicine (e.g., internet or telephone-based therapy) as a potential venue for my psychotherapy treatment. I understand that telemedicine includes the practice of health care delivery, including mental health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, and/or data communications.
I understand that I have the following rights with respect to telemedicine:
- I have the right to withhold or withdraw this consent at any time without affecting my right to future care or treatment, either face-to-face or remotely.
- The laws that protect the confidentiality of my medical information also apply to telemedicine. As such, I understand that the information disclosed by me during the course of my therapy is generally confidential; however, I also understand that here are both mandatory and permissive exceptions to confidentiality (see Client Confidentiality and HIPAA Notice of Privacy Practices forms, provided to me, for more details of confidentiality and other related issues.) Apart from these exceptions, I understand that the dissemination of any personally identifiable images or information from the telemedicine interaction to other entities shall not occur without my written consent.
- I understand that there are benefits associated with telemedicine, although results cannot be guaranteed or assured. These benefits may include: a greater ability to express thoughts and emotions; avoidance of transportation and travel difficulties; minimized time constraints; and greater opportunity to prepare in advance for sessions.
- I also understand that there are risks and consequences associated with telemedicine. These may include, but are not limited to, the possibility, despite reasonable efforts on the part of my psychotherapist, that: the transmission of my medical information could be disrupted or distorted by technical failures; the transmission of my medical information could be interrupted by unauthorized persons; the electronic storage of my medical information could be accessed by unauthorized persons; and/or misunderstandings can more easily occur, particularly when care is delivered in an asynchronous manner. In addition, I understand that telemedicine-based services and care may not yield the same results nor be as complete as face-to-face service. I also understand that if my psychotherapist believes I would be better served by another form of psychotherapeutic service (e.g. face-to-face service), I will either be provided or referred to those services.
- I understand that I have the right to access my medical information and copies of medical records in accordance with the law.
- I understand that even if I choose to use my insurance benefits, I will remain fully responsible for the therapist’s fee for telemedicine sessions. I understand that telemedicine may not be covered by my insurance company, and while my therapist will make every reasonable effort to obtain and provide me with accurate and up-to-date telemedicine benefit information, I am ultimately responsible for knowing my own benefits and for ensuring prompt payment of therapy fees, whether or not my insurance company decides to reimburse.
I have read and understand the information provided above. I also have discussed it with my psychotherapist, and all of my questions have been answered to my satisfaction.