Online Consultation Consent Form

Telepsychiatry is the delivery of psychiatric services using interactive audio and visual electronic systems between a provider and a patient who are not in the same physical location. The interactive electronic systems used in Telepsychiatry incorporate network and software security protocols to protect the confidentiality of the patient’s information, audio and visual data. These protocols include measures to safeguard the data and aid in protecting against intentional or unintentional corruption.

• Increased accessibility to psychiatric care.
• Patient convenience.

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

• Information transmitted may not be sufficient (e.g. poor resolution of video) to allow appropriate decision-making by your provider.
• Your provider may not be able to provide medical treatment using interactive electronic equipment nor provide or arrange for emergency care that you may require.
• Delays in medical evaluation and treatment may occur due to deficiencies or failures of the equipment.
• Security protocols can fail, causing a breach in privacy of confidential health information.
• A lack in accessibility to all the information that might be available in a face to face visit, thus a Telepsychiatry session may result in errors in judgement.

• I understand that the laws that protect the privacy and confidentiality of medical information also apply to Telepsychiatry.
• I have the right to withhold or withdraw my consent to the use of Telepsychiatry during the course of care at any time. I understand that my withdrawal of consent will not affect any future care or treatment.
• I have the right to inspect all medical information that includes the Telepsychiatry visit. I may obtain copies of this medical record information for a reasonable fee.
• I understand that my provider has the right to withhold or withdraw consent for the use of Telepsychiatry during the course of care at any time.
• I understand that the laws that protect the privacy and confidentiality of medical information also apply to Telepsychiatry.
• I understand that the all rules and regulations that apply to the provision of healthcare services in Australia also apply to Telepsychiatry.

• 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 I must be a resident of Australia to be eligible for Telepsychiatry services from my provider.

I have read and understood the above information provided regarding Telepsychiatry.

I have discussed it with my provider and all my questions have been answered to my satisfaction.

I hereby give my informed consent for the use of Telepsychiatry in my health care and authorise my provider to use Telepsychiatry in the course from my diagnosis through to my treatment.