1. PURPOSE. The purpose of this form is to obtain your consent to participate in telecare counseling with a Jewish Family Service of the Desert (JFS) Licensed Therapist.
2. NATURE OF TELECARE COUNSELING. Telecare involves the use of audio, video, or other electronic communications to interact with you, consult with your Therapist, and/or review your medical information for the purpose of diagnosis, therapy, follow-up, and/or education. During your telecare counseling, details of your medical history and personal health information may be discussed.
3. RISKS, BENEFITS. The benefits of telecare include having access to a Licensed Clinician for therapy without having to travel outside of your home or local health care community.
4. A potential risk of telecare is that, in rare circumstances, security protocols could fail causing a breach of patient privacy. You may decline telecare services if you so wish.
5. PROTECTED HEALTH INFORMATION AND RECORDS. All laws concerning patient access to medical records and copies of medical records apply to telecare. Dissemination of any patient identifiable images or information from the session or other entities shall not occur without your consent.
6. CONFIDENTIALITY. To the best of the therapist’s and agency’s ability, all existing confidentiality protections under federal HIPAA and California law apply.
7. RIGHTS. You may withhold or withdraw your consent to telecare at any time before and/or during the session without affecting your right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled.
My health care provider has discussed with me the information provided above. I have had an opportunity to ask questions about this information and all of my questions have been answered.