Telepsychiatry is the delivery of psychiatric services using interactive audio and visual electronic systems between a provider and a patient that are not in the same physical location. These services may also include electronic prescribing, appointment scheduling, communication via email or electronic chat, electronic scheduling, and distribution of patient education materials.
The potential benefits of telepsychiatry are:
The potential risks of telepsychiatry include, but are not limited to:
There could be some technical problems (video quality, internet connection) that may affect the telepsychiatry session.
Pure Psychiatry of Michigan utilizes software that meets the recommended standards to protect the privacy and security of the telepsychiatry sessions.
Alternatives to the use of telepsychiatry:
Traditional face-to-face sessions.
I understand that I have the following rights with respect to telepsychiatry:
The laws that protect the confidentiality of my medical information also apply to telepsychiatry. As such, I understand that the information disclosed by me during the course of my treatment isconfidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding.
I also understand that the dissemination of any personally identifiable images or information from the telepsychiatry interaction to researchers or other entities shall not occur without my written consent.
I understand that there arerisks and consequences from telepsychiatry, including, but not limited to, the possibility, despite reasonable efforts on the part of my psychiatrist, 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; and/or the electronic storage of my medical information could be accessed by unauthorized persons.
In addition, I understand that telepsychiatry based services and care may not be as complete as facetoface services. I also understand that if my psychiatrist believes I would be better served by another form of psychiatric services (e.g. faceto face services) I will be referred to a psychiatrist who can provide such services in my area. Finally, I understand that there are potential risks and benefits associated with any form of psychiatry
I understand that I have a right to access my medical information and copies of medical records in accordance with Michigan Law, for a $10.00 fee
• I will not record any telepsychiatry sessions without written consent from my provider. I understand that my provider will not record any of our telepsychiatry sessions without my written consent.
• I will inform my provider if any other person can hear or see any part of our session before the session begins. The provider will inform me if any other person can hear or see any part of our session before the session begins.
• I understand that I, not my provider, am responsible for the configuration of any electronic equipment used on my computer that is used for telepsychiatry. I understand that it is my responsibility to ensure the proper functioning of all electronic equipment before my session begins.
• I understand that my psychiatrist determines whether or not the condition being diagnosed and/or treated is appropriate for a telepsychiatry encounter.
• I understand that if the telepsychiatry session does not achieve everything that is needed, then I will be given a choice about what to do next. This could include a follow up face-to- face visit, or a second telepsychiatry visit.
• I understand that post COVID-19 it is my responsibility to contact my insurance company to verify telepsychiatry coverage.
By signing below, I confirm that I have verified my behavioral health benefits with my insurance company and that telehealth is a covered benefit under my insurance plan. If not, I understand that I am responsible for the cost of any telehealth visit not covered by my insurance company.
Patient Consent to The Use of Telepsychiatry:
I hereby consent to engaging in telepsychiatry with Adrian Counseling and Psychiatric Clinic as part of my psychiatric evaluation and treatment. I understand that "telepsychiatry" includes the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, or data communications. I have read and understand the information provided above regarding telepsychiatry.