I understand that telemedicine (real-time audio/video teleconference session) is 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 Simone Cromwell, LMFT, providing healthcare services to me via telemedicine.
I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine. As always, if you utilize insurance, your carrier will have access to your medical records for quality review/audit.
I understand that my insurance carrier may not cover telemedicine and I will be responsible for any copayment, deductible or coinsurance that apply to my telemedicine visit. This may or may not be the same cost as face-to-face sessions. I will be responsible for checking on whether or not my insurance will cover these services.
I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment. I can revoke my consent orally or in writing at any time by contacting my provider. As long as this consent is in force (has not been revoked) my provider may offer health care services to me via telemedicine without the need for me to sign another consent form.
I understand that Simone Cromwell, LMFT, will provide care for me in specific situations through a secure, HIPAA compliant electronic platform. These situations may include when I am temporarily unable to attend a face to face session due to illness or emergency measures in place. I also understand that it is my responsibility to choose a location, a time, a network and a device that maintains my privacy and prevents interruption during a telehealth session.
I understand that certain situations including emergencies and crises may be inappropriate for audio, video and/or computer based psychological services. If I am in crisis or I am experiencing a medical or psychiatric emergency, I should immediately call 911 or go to the nearest hospital or crisis facility.