Tele-Psychiatry Consent Form

You MUST be a  NEW YORK STATE RESIDENT to participate in tele-medicine services provided by Binu Chacko MD. PC. and proof of residence must be provided prior to conducting sessions.

The benefits of having a video consultation can be:

Obtaining continued psychiatric services during Pandemic or other states of emergency.

Reducing the waiting time to see a specialist or delayed psychiatric outpatient services.

Avoiding your need to travel to distant services.

Assisting your local/primary health service provider to better look after you.

 

The risks of having a video consultation can be:

A video consultation will not be exactly the same, and may not be as complete and comprehensive as a face-to-face service.

There could be some technical problems that affect the video visit.

This health care service uses HIPAA complaint systems that meet recommended standards to protect the privacy and security of the video visits.

However, the service cannot guarantee total protection against hacking or tapping into the video visit by outsiders. This risk is small, but it does exist.

If the video visit 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, telephone visit, or a second video visit.

I can change my mind and stop using video consultations at any time, including in the middle of a video visit. This will not make any difference to my right to ask for and receive health care. 

 

I hereby consent to engaging in telemedicine with Binu Chacko MD., as part of my psychiatry evaluations and medication management sessions. I understand that "telemedicine" includes the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, or data communications. I understand that telemedicine also involves the communication of my medical/mental information, both orally and visually, to health care practitioners located in New York or outside of New York.

I understand that I have the following rights with respect to telemedicine:

(1) I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment nor risking the loss or withdrawal of any program benefits to which I would otherwise be entitled.

(2) The laws that protect the confidentiality of my medical information also apply to telemedicine. As such, I understand that the information disclosed by me during the course of my therapy is generally confidential. 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 telemedicine interaction to researchers or other entities shall not occur without my written consent.

(3) I understand that there are risks and consequences from telemedicine, 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 telemedicine based services and care may not be as complete as face-to-face services. I also understand that if my psychotherapist believes I would be better served by another form of psychiatric services (e.g. face-to-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, and that despite my efforts and the efforts of my psychiatrist, my condition may not be improve, and in some cases may even get worse.

(4) I understand that I may benefit from telemedicine, but that results cannot be guaranteed or assured.

(5) I understand that I have a right to access my medical information and copies of medical records in accordance with New York Law.

 

I have read and understand the information provided above. I have discussed it with my psychiatrist and all of my questions have been answered to my satisfaction.