Introduction
Tele-psychiatry is the delivery of psychiatric services using interactive audio and visual electronic systems between a provider and a patient that are not in the same physical location. The interactive electronic systems used in Tele-psychiatry incorporate network and software security protocols to protect the confidentiality of patient information and audio and visual data. These protocols include measures to safeguard the data and to aid in protecting against intentional or unintentional corruption and are HIPPA compliant.
Potential Benefits
• Increased accessibility to psychiatric care.
• Patient convenience.
Potential Risks
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 for appropriate decision-making by your provider.
• Your provider may not be able to provide medical treatment using interactive electronic equipment nor provide for 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 of privacy of confidential health information.
• A lack of access to all the information that might be available in a face to face visit, but not in a Tele-psychiatry session, may result in errors in judgment.
Alternatives to the Use of Tele-psychiatry
Traditional face-to-face sessions in your provider’s office.
Patient’s Rights
• I understand that the laws that protect the privacy and confidentiality of medical information also apply to Tele-psychiatry.
• I understand that pursuing treatment via tele-psychiatry is a decision I made and that I may withdraw my consent to the use of Tele-psychiatry during the course of my 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 Tele-psychiatry 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 Tele-psychiatry during the course of my care at any time.
• I understand that the laws that protect the privacy and confidentiality of medical information also apply to Tele-psychiatry.
• I understand that the all rules and regulations that apply to the provision of healthcare services in the State of Texas also apply to Tele-psychiatry.
Patient’s Responsibilities
• I will not record any Tele-psychiatry sessions without written consent from my provider. I understand that my provider will not record any of our Tele-psychiatry 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 Tele-psychiatry. 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 the State of Florida and be located in the state of Florida at the time of service in order to be eligible for Tele-psychiatry services from my provider.
• I have a right to file a complaint with the Florida Medical Board. Complaints about physicians, as well as other licensees and registrants of the Florida Medical Board, including physician assistants, acupuncturists, and surgical assistants may be reported for investigation.
Required Information at Every Visit
1) Address and telephone number of the patient at time of session. This is to ensure that your clinician is aware of alternative means of treatment should an emergency occur
Rights and Responsibilities of the Provider
1) Due to Texas state law regarding tele-psychiatry, The Morrison Clinic will require an in office appointment within 72 hours if a new condition is treated in your tele-psychiatry appointment.
2) The Morrison Clinic reserves the right to assess suitability and appropriateness of tele-psychiatry candidates due to the potential limitations of the treatment modality mentioned above.
3) In the event of imminent danger, the provider is legally and ethically bound to report information to authorities, family members, or others, to minimize potential harm.
Cancellation and Late Policy
“No-shows” will be charged a $25.00 fee which must be paid prior to scheduling another appointment.
Cancellations within 48 business hours of appointment time will be charged $25.00 fee which must be paid prior to scheduling another appointment.
Cancellations outside of 48 business hours of appointment time: we will gladly reschedule, and no fee will be charged.
Patient Consent To The Use of Tele-psychiatry
I have read and understand the information provided above regarding Tele-psychiatry.
I have discussed it with my provider and all of my questions have been answered to my satisfaction.
My signature below affirms that I hereby give my informed consent for the use of Tele-psychiatry in my health care and authorize my provider to use Tele-psychiatry in the course of my diagnosis and treatment.