Informed Consent for Telehealth Services
The purpose of this informed consent form (this "consent") is to (1) describe general information related to the healthcare services provided by Modern Psychiatry, P.A. and its affiliated medical practices and providers, including, but not limited to, Modern Psychiatry NY, P.C., Modern Psychiatry NJ, P.C., and Modern Psychiatry CA, P.C. (collectively "Modern PsY.chiat[Y."); (2) outline the benefits, risks, and limitations of such services; and (3) provide you with written information regarding the privacy and confidentiality of your health information. By signing this consent, you acknowledge, understand, and voluntarily consent to the statements in this form and all treatment and healthcare-related services described herein. Please carefully review the information in this Consent document before signing. You may wish to speak with one of our providers or your primary care provider before proceeding. If you decide to proceed, please sign as indicated at this document's end. Modern Psychiatry will not be able to provide any services unless you confirm by signing below or otherwise acknowledge in writing that you have read, understood, and agree to this consent.
Information About Telehealth
Telehealth involves using two-way videoconferencing to enable you to participate in treatment sessions with your provider from a remote location, such as your home or another private location. Treatment sessions are similar to in-person sessions in that you and your provider can communicate in real-time while seeing each other over live video. While telehealth is similar to in-person care, there are differences.
Expected Benefits
Telehealth may provide the following benefits:
• Improved access to medical care enables you to remain in your location while the provider may provide services to you from a distant site.
• Greater flexibility and consistency in scheduling.
• Greater efficiency in diagnosis, treatment, medical evaluation, and management.
• The opportunity to obtain expertise from a distantly located provider.
• Ongoing care and follow-up communication with a provider.
Possible Risks
As with any type or form of healthcare treatment, there are potential risks associated with the use of telehealth, including:
• Reduced ability to perform certain aspects of a physical examination or evaluation.
• Insufficient information to allow for appropriate medical decision-making by your provider (e.g., poor resolution of images or audio).
• Technical problems or failures of electronic equipment interrupting or delaying treatment sessions.
• Failure of privacy and security protections resulting in a breach of protected health information.
Telehealth Platform
• Telehealth appointments will be conducted through the HIPAA-compliant, encrypted platform called ICANotes. Unfortunately, we cannot use any other videoconferencing platforms.
• Your provider will explain how to use the platform, and more patient information can be found at www.icanotes.com.
• During the session, you must use a camera-enabled computer, tablet, or smartphone.
• Please advise your provider of an alternate telephone number or other contact method if technical problems interrupt your session.
• It is important for your provider to know where you are physically located during your treatment session in case an emergency arises. Please try to establish a consistent location for you to participate in telehealth sessions.
In-Person Care
• You have the right to discontinue treatment sessions and proceed through in-person care if you feel it would be more beneficial to you.
• Your provider may determine that telehealth is no longer appropriate and refer you for in-person treatment sessions.
• At the discretion of your provider and for controlled substance prescriptions (see Section XI), you may be required to participate in periodic in-person visits in addition to your telepsychiatry sessions.
• If the patient is a minor (see Section X), then the parent of such patient will be responsible for ensuring that the patient is available for in-person care as requested by the provider.
• In an emergency, your provider may advise you to proceed to an emergency room or other direct care facility for further evaluation and treatment. Please designate at least one emergency contact person and the closest emergency room to your location.
Privacy and Confidentiality
• It is important for you to be in a quiet, private space that is free of distractions during sessions.
• It is important to use a secure internet connection during sessions rather than public or free Wi-Fi.
• Treatment sessions will not be recorded without the express permission of all participants, including you and your provider.
• Please review our policies and your rights concerning your private and confidential information at www.mymodernpsychiatry.com.
Scheduling and Billing
• It is important for you to be on time for all appointments. If you need to cancel or change your appointment, you must notify your provider in advance by telephone.
• You are responsible for confirming with your insurance company that your plan covers telehealth sessions. If they are not covered or are only partially covered, you will be responsible for full payment for any services provided.
Medical History
• It is important that we have access to your full medical history to ensure effective treatment.
• These services are intended to be an addition to, and not a replacement for, services provided by your primary care provider. Modern Psychiatry will coordinate your care with your current primary care provider.
• If we cannot obtain an adequate medical history from your primary care provider, or you do not have a primary care provider, you agree to be referred to a Modern Psychiatry affiliated primary care provider for evaluation.
Minor Patients
• All minors receiving treatment must be accompanied by a parent or legal guardian.
• For minor patients, we require written consent from a parent or legal guardian before your receipt of services (see signature section below).
• The definition of "minor" regarding requests for mental health services may vary by state. Please ask us for further information before signing this consent.
Controlled Substances
• If your provider prescribes any controlled substances to you during the course of your treatment, you may be required to participate in periodic in-person visits in addition to your telepsychiatry sessions.
• Modern Psychiatry does not prescribe controlled substances to any individual over the age of eighteen (18). If any patient nearing eighteen (18) years of age is being prescribed controlled substances during their treatment, Modern Psychiatry will ensure a safe and orderly transition of that patient's care to another provider in a way that promotes the highest quality of care possible.
Patient Consent for the Use of Telehealth
By signing this form, you acknowledge and agree to the following:
• You have read and understand all expected benefits and risks associated with telehealth, discussed this with your provider, and any questions have been answered to your satisfaction.
• You understand that you have the right to withhold or withdraw your consent to the use of telehealth during your care at any time without affecting your right to future care or treatment.
• You understand that the laws that protect the privacy and the confidentiality of medical information also apply to telehealth and that appropriate measures will be taken to secure transmitted information and maximize privacy and confidentiality.
You hereby give your informed consent for using telehealth in your medical care.