Telehealth Agreement
I understand that telehealth or teletherapy involves the use of electronic information and communication technologies by a health care provider to deliver services to an individual when he/she is located at a different site than the provider; and hereby consent to receiving health care services to me via telehealth over secure video conferencing platform.
I understand
Client/Parent Initials
*
I understand that the laws that protect privacy and the confidentiality of my medical information also apply to telehealth or teletherapy.
I understand
Client/Parent Initials
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I understand that while telehealth or teletherapy treatment has been found to be effective in treating a wide range of disorders, there is no guarantee that all treatment of all clients will be effective. I also understand that there are potential risks involving technology, including but not limited to: Internet interruptions, and technical difficulties. I understand that technical difficulties with hardware, software, and internet connection may result in service interruption and that the health care provider is not responsible for any technical problems and does not guarantee that services will be available or work as expected.
I understand
Client/Parent Initials
*
I understand that I am responsible for information security on my computer and in my own physical location. I understand that I am responsible for creating and maintaining my user name and password and not share these with another person. I understand that I am responsible to ensure privacy at my own location by being in a private location so other individuals cannot hear my conversation.
I understand
Client/Parent Initials
*
I understand that my health care provider or I can discontinue the telehealth/teletherapy services if it is felt that this type of service delivery does not benefit my needs.
I understand
Client/Parent Initials
*
Thank you for understanding our Telehealth Policy. Please let us know if you have any questions or concerns.
I have read and understand the information provided above regarding telehealth or teletherapy, have discussed itwith my health care provider and all of my questions have been answered to my satisfaction. I hereby give myinformed consent for the use of telehealth or teletherapy in my care.
Signature
Name of Client
First Name
Last Name
Name of Parent/Guardian/Responsible Party
First Name
Last Name
Email
example@example.com
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Submit
Should be Empty: