A Family Connextion

 

Under the laws of the United States and the state of New York your Personal Health Information (PHI) must be kept private. It is also required by law to give you this notice and to follow the terms of this notice while it is in effect.

 

Changes in these privacy practices are allowed at any time as long as those changes are permitted or required by law. Any changes in these privacy practices will affect how the privacy of your PHI is protected, including any PHI received about you or created in the course of your therapy. These changes could also affect the protection of the privacy of any of your PHI received before the changes. If changes are made, a new notice will be available to you.

Your PHI will not be used or disclosed for any purpose not listed below, without your specific written authorization. You must give written authorization to disclose your health information to anyone for any reason you want. Any specific written authorization you provide may be revoked at any time by your written request.

 

 Health Care Provider - PHI may be used and disclosed to your physician or other healthcare provider who is also treating you.

 

 Payment - Your PHI may be used and disclosed to your health plan or other third party for payment of services provided for you. If your contract with your insurance company requires that information relevant to the services provided be given before payment, providing them with a clinical diagnosis, as well as clinical information such as treatment plans or summaries and/or copies of any records maintained about your therapy sessions may be required.

 

 Health Care Operations - Your PHI may be used and disclosed to staff members for the purpose of obtaining insurance eligibility, billing health insurance and inquiring about claim status.

 

 As Law Requires - Your PHI may be used and disclosed to any person required by federal, state, or local laws to have lawful access to your treatment program.

 

 Court Orders, Judicial and Administrative Proceedings, and Law Enforcement - Your PHI may be disclosed as part of a court proceeding, in response to a subpoena, or in other situations as required by law.

 

 Appointment Reminders - You may be contacted by phone or email for an appointment reminder. If contact is by phone, a recorded message may be left on your answering machine.

 

 Cancellation Policy– We understand that there are times when you must miss an appointment due to emergencies or obligations for work or family. However, when you do not call to cancel an appointment, you may be preventing another patient from getting much-needed treatment.
Conversely, the situation may arise where another patient fails to cancel and we are unable to schedule you for a visit, due to a seemingly “full” appointment book.
If an appointment is not canceled at least 24 hours in advance you will be charged a one hundred dollar fee($100.00) fee; this will not be covered by your insurance company.

 

 Victims of Abuse, Neglect, or Domestic Violence - Your PHI may be used or disclosed to authorized persons from state agencies in cases of disclosures required by applicable state laws governing abuse, neglect, criminal activities, threats to the health/safety of the client and others, domestic violence, etc. In the case of minor children, the law requires such information to be disclosed.

 

 Event of an Emergency - Your PHI may be disclosed to a family member, a person responsible for your care, or your personal representative in the event of an emergency. If you are present in such a case, you will be given an opportunity to object. If you object or are not present or are incapable of responding, your PHI will be used or disclosed in your best interest at that time. In so doing, only the aspects of your PHI that are necessary for response to the emergency will be used or disclosed.

Communication

We are committed to ensuring that your privacy is protected. Should we ask you to provide certain information by which you can be identified when using this website; you can be assured that it will only be used in accordance with this privacy statement.

We will not intentionally share the contents of any email or information submitted via the internet with any third party. However, due to the nature of electronic communications, we cannot and do not provide any assurances that the contents of your email will not become known or accessible to third parties. We urge you not to provide any confidential information to us via electronic communication. Should you choose to communicate via email, the provider contacted will respond to any emails sent until you request that form of communication to cease. Please take all precautions necessary to secure your email should you choose to use it to contact the provider.

A Family Connextion Telehealth Informed Consent

Introduction of Telebehavioral Health:

 As a client receiving behavioral services through telebehavioral health technologies, I understand that:

    Telebehavioral health is the delivery of behavioral health services using interactive technologies (use of audio, video, or other electronic communications) between a practitioner and a client who is not in the same physical location.

    The interactive technologies used in behavioral health incorporate network and software security protocols to protect the confidentiality of client information transmitted via any electronic channel.  These protocols include measures to safeguard the data and to aid in protecting against intentional or unintentional corruption.

Software Security Protocols:

    Electronic systems used will incorporate network and software security protocols to protect the privacy and security of health information and will include measures to safeguard health information to ensure its integrity against intentional or unintentional corruption.

Benefits & Limitations:

    This service is provided by technology (including, but not limited to, video, phone, text, apps, and e-mail) and may not involve direct face-to-face communication.  There are benefits and limitations to this service. Sessions initiated by either therapist or client for more than 20 minutes will be charged for the full 60 minutes, even if the internet connection fails. 

    I understand that I may expect the anticipated benefits such as improved access to care and more efficient evaluation and management from the use of telebehavioral health in my care, but that no results can be guaranteed or assured.

I understand that if my provider believes that I would be better served by some other form of intervention (e.g., face-to-face services), I will be referred to a mental health professional. 

Technology Requirements:

    I will need access to, and familiarity with, the appropriate technology in order to participate in the service provided.

Exchange of Information:

    The exchange of information will not be direct and any paperwork exchanged will likely be provided through electronic means or through postal delivery.

    During my telebehavioral health consultation, details of my medical history and personal health information may be discussed with me or other behavioral health care professionals through the use of interactive video, audio, or other telecommunications technology.

 

Local Practitioners:

    If a need for direct, in-person services arises, it is my responsibility to contact practitioners in my area, providers referred to me by my telebehavioral health provider, or to contact my behavioral practitioner’s office for an in-person appointment or my primary care physician if my behavioral practitioner is unavailable.  I understand that an opening may not be immediately available in either office.

Self-Termination:

    I may decline any telebehavioral health services at any time without jeopardizing my access to future care, services, and benefits.

Risks of Technology:

    These services rely on technology, which allows for greater convenience in service delivery.  There are risks in transmitting information over technology that include, but are not limited to, breaches of confidentiality, theft of personal information, and disruption of service due to technical difficulties.

Modification Plan:

    My practitioner and I will regularly reassess the appropriateness of continuing to deliver services to me through the use of the technologies we have agreed upon and modify our plan as needed.

Emergency Protocol:

    In emergencies, in the event of disruption of service, or for routine or administrative reasons, it may be necessary to communicate by other means.

    A Family Connextion does not offer behavioral health emergency or crisis management services.  As part of your mental health treatment plan, community options for mental health crisis management will be discussed on an individual basis. By signing this document, I agree that certain situations, including emergencies and crises, are inappropriate for audio-/video-/computer-based psychotherapy services.  If I am in crisis or in an emergency, I should immediately call 9-1-1 or seek help from a hospital or crisis-oriented healthcare facility in my immediate area.

Payment for Telehealth Services:

    A Family Connextion will bill insurance for telehealth services when these services are determined to be covered by an individual’s insurance plan.  In the event that insurance does not cover telehealth, the individual wishes to pay out-of-pocket, or when there is no insurance coverage, we will provide you with a statement of service to submit to your insurance company if you wish. Copays will be paid either before or during each therapy session. Copays are determined by your insurance company. 

*** Same-day cancellation of an appointment is subject to a one hundred dollar ($100.00) cancellation fee.

 

Client Consent to the Use of Telehealth:

    I have read and understand the information provided above regarding telebehavioral health services.  I understand the risks and benefits related to the use of telebehavioral health services and have had my questions regarding the procedure explained.  I hereby give my informed consent to participate in the use of telehealth services for treatment under the terms described herein.

You may contact the secretary of the United States Department of Health and Human Services with questions or to register complaints about any licensed mental health professional.

Please type your name below to indicate consent to telehealth treatment.

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If patient is a minor, the parent or guardian must sign below to consent to the minor receiving treatment.