PHOENIX PREFERRED CARE, INC.

INFORMED CONSENT for TELEHEALTH SERVICES

 

INTRODUCTION

Telehealth involves the use of electronic communications to enable behavioral health care providers at different locations to share individual client medical information for the purpose of improving behavioral health client care. Certain individuals might have authorized or unauthorized access to such records or transmissions (e.g., colleagues, supervisors, employees, administrative assistants, billing personnel, information technology specialists, etc.). The information may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:

·         Client medical records

·         Behavioral health images

·         Live two-way audio and video

·         Output data from medical devices and sound and video files

Electronic systems used will incorporate network and software security protocols to protect the confidentiality of client identification. Imaging data will include measures to safeguard the data and to ensure its integrity against intentional and unintentional corruption.

EXPECTED BENEFITS

·         Improve access to behavioral health care by enabling you to maintain access to your behavioral health provider from a remote site.

·         More availability for the members of your treatment team to become part of your behavioral health treatment through the virtual meeting room.

·         Obtaining expertise of a behavioral health professional without being required to drive to the office. 

POSSIBLE RISKS

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

·         In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the behavioral health professional and/or case manager.

·         Delays in behavioral health evaluations and treatment could occur due to deficiencies or failures in equipment.

·         In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information.

·         In the event an appointment is compromised due to technology failure, you will be contacted via telephone to reschedule.

You have the option to schedule a face-to-face appointment at a Phoenix Preferred Care office or alternate referrals may be made to providers in your area if you choose not to participate in Telehealth at Phoenix Preferred Care. 

By signing this form, I understand the following:

I understand that the laws that protect 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 without my consent.

I understand that I have the right to withhold or withdraw my consent to the use of Telehealth in thecourse of my care at any time. Without affecting my right to future care or treatment.

I understand that I have the right to access my medical record, and may receive copies o fthis information upon written request.

I understand that a variety of alternative methods of behavioral health care may be available tome, and that I may choose one or more of these at any time.

I understand that Telehealth may involve electronic communication of my personal medical information to other medical practitioners.

I understand that it is my duty to inform my behavioral health provider of all my healthcare information, such as appointments with other providers and accurate medication information, to maintain continuity of my care.

I understand that no anticipated treatment results can be guaranteed or assured.

PATIENT CONSENT to the USE OF TELEHEALTH SERVICES

I have read and understand the information provided above regarding Telehealth, have discussed it with my behavioral health provider as may be designated, and all of my questions have been answered to my satisfaction.

I hereby give my informed consent for the use of Telehealth in my behavioral health care.

 

Emergency Procedures:

CALL 911 OR LOCAL EMERGENCY RESPONSE TEAM.

GO TO THE NEAREST EMERGENCY ROOM.

CONTACT YOUR LOCAL CRISIS CENTER.

TEXT THE CRISIS TEXT LINE BY SENDING THE MESSAGE "HOME" TO 741741.

CONTACT THE NATIONAL SUICIDE HOTLINE AT 1-800-273-TALK 8255.

PLEASE DO NOT LEAVE A VOICEMAIL MESSAGE TO COMMUNICATE AN EMERGENCY, AS IT MAY NOT BE CHECKED IN THE URGENT MANNER WHICH IT REQUIRES.