EXCEL PSYCHIATRIC CONSULTATION

13243 Executive Park Terrace, Germantown MD, 20874

Tel: 301-820-1715 Fax: 240-597-1060

Telehealth/Telepsychiatry Consent Form

Telepsychiatry is a form of two-way, real time, video conferencing. Interactions between patients and providers are confidential and are provided using a HIPPA compliant platform. Network and software security protocols are put in place to protect the confidentiality of patient identification and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

The information gathered may be used for diagnosis, therapy, follow-up, and may include any of the following:

• Patient medical records
• Medical images
• Live two-way audio and video
• Output data from medical devices and sound and video files

Expected Benefits:

Improved access to medical care by enabling a patient to remain in his/her local healthcare site (i.e. home) while the physician consults and obtains test results at distant/other sites.

Possible Risks:

As with any medical procedure, there are potential risks associated with the use of telemedicine. These risks include, but may not be limited to:

• The quality of transmitted data may affect the quality of services provided by the provider . In rare cases, the provider may determine that the transmitted information is of inadequate quality, thus necessitating a face to-face meeting with the patient, or at least a rescheduled video consult;
• Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment;
• In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information;
• In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors;

Eligibility Criteria:

• Must be 18 years or older to participate in Telehealth
• Must be located in the state of Maryland during the time of the session
• Must have access to a computer or smart device that will allow both, audio and video connection that is of sufficient quality
• Must be in a private or isolated setting during a time of the session
• Must always maintain a valid phone number in records

Payment Policy:

Telepsychiatry sessions are covered by some of the insurance payors. I understand and agree that I am fully financially responsible for charges not paid by insurance company.

Camera and microphone access:

When you start a video call for the first time, you need to let the provider use your camera and microphone.

Video call requirements:

• Broadband connection to the Internet

• A built-in web camera or external camera. You must have an Email account to join the session.

Patient Consent To The Use of Telemedicine/Telepsychiatry:

1. I understand that the laws that protect the privacy and the confidentiality of medical information also apply to Telehealth and that no information obtained in the use of Telehealth which identifies me will be disclosed to researchers or other entities without my consent.

2. I understand that I have the right to withhold or withdraw my consent to the use of Telehealth through the course of my care at any time, without affecting my right to future care or treatment.

3. I understand that Ihave the right to inspect all information obtained and recorded through the course of a Telehealth interaction and may receive copies of this information for a reasonable fee.

4. I understand that a variety of alternative methods of medical care may be available to me and that I may choose one or more of these at any time.

5. I understand that Telehealth may involve electronic communication of my personal medical information to other medical practitioners who may be located, in other areas, including out of state.

6. I understand that it is my duty toi nform my psychiatrist regarding my care that I may have with other healthcare providers.

7. 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.

8. I understand that Telehealth uses a high quality, real-time audiovisual link using HIPAA compliant platform. If there is any disruption in the connection, a clinician will try to re- establish the connection as soon as possible, if we are unable to do so, we will call you immediately on your phone number in our files.

9. I understand that in case of an emergency,my clinician will call 911 to get me appropriate care, as my clinician is not physically present with me, my clinician has limitations to assist me.

10.I understand that my clinician has the right to use his/her own judgment to determine if I am a suitable and appropriate client for using Telehealth.

11.I understand that my clinician may request me to be seen in the office as and when needed and I will comply with these requests.

12.I understand that the first visit will be a face to face visit in the office with my psychiatrist

13.I understand and agree that the Telehealth session will not be used for emergency visits or crisis intervention. During emergency situations, I agree to follow up in the office for face to face visit

14.I recognize the inability to have direct, physical contact with the patient is a primary difference between telehealth and direct in-person service delivery

15. Changes in the environment and test conditions could be impossible to make during delivery of telehealth services. Telehealth services may not be provided by correspondence only

I have read and understand the information provided above regarding telemedicine, have discussed it with my physician or such assistants as may be designated, and all of my questions have been answered to my satisfaction.

I have read this document carefully, and understand the risks and benefits of the teleconferencing consultation and have had my questions regarding the procedure explained and I hereby give my informed consent to participate in a telemedicine visit under the terms described herein.

By signing below, I hereby state that I have read, understood, and agree to the terms of this document.