Telepsychiatry Contract and Informed Consent

PLEASE READ THIS DOCUMENT CAREFULLY

Sessions and visits will be held in person or via "telepsychiatry": using video conferencing software with audio capability and/or a separate software/device for audio (e.g, telephone, headset, etc Of note, telepsychiatry establishes a formal provider-patient relationship used to maintain regular assessment, diagnostics, therapy, and/ or prescription.

We will be utilizing Health Insurance Portability and Accountability Act (HIPAA) protected software to ensure that your protected health information is secure from unauthorized access and that confidentiality is maintained. This document serves as a consent form for treatment via telepsychiatry in general.

Benefits of Telepsychiatry Telepsychiatry stands at the crossroads of cutting-edge technology and formal behavioral health services. You can expect the following benefits: 1) Telepsychiatry eliminates barriers to accessing healthcare and provides an alternative means to obtain behavioral health services for patients who may otherwise have limited accessibility or encounter prolonged waiting lists in the community. 2) In addition to removing the burden of travel time to a physical medical office as well as the risks and costs associated with transportation, telepsychiatry allows for flexible scheduling. 3) Telepsychiatry offers a reduction of stigma by providing private treatment in the comfort of the patient's personal space. 4) Telepsychiatry can provide treatment to patients with disabilities and limited mobility without requiring extensive planning for transport.

Limitations of Telepsychiatry While it is not possible to anticipate all the limitations of any treatment, you should consider the following when consenting to treatment via telepsychiatry: 1) Telepsychiatry audiovisual equipment may experience technical difficulties. 2) While every precaution is taken to secure patient data and maintain confidentiality, the nature of electronic appointments results in additional exposure to security breaches. 3) Telepsychiatry may not be suitable for certain illnesses that require higher levels of care. 4) Certain illnesses may not be adequately treated by telepsychiatry. 5) Due to law, controlled substance cannot be prescribed through telepsychiatry. These substances are subject to addiction, abuse, and illegal diversion. As such, safer and lawful alternatives can be considered.

As telepsychiatry is generally conducted remotely, safety protocols and alternate means of seeking help will be addressed in detail in your consultation. However, the following are generally accepted alternatives to treatment via telepsychiatry: 1) You may elect to seek treatment in a more traditional, in-office visit with another provider. Note that current evidence via rigorous studies has shown that treatment via telepsychiatry is equivalent to face-to- face visits with a psychiatrist.

2) Pursuing treatment via telepsychiatry is a decision made by you. If you choose to revoke your decision and pursue alternate treatment, you are able to withdraw your consent at any time. (Of course, we recommend discussing this decision with your psychiatrist first. We also recommend establishing your next provider prior to termination to eliminate any gaps in treatment

Required Information at Every Visit 1) Name, location, and telephone number of the patient at time of session. This is to ensure that your psychiatrist is aware of alternative means of treatment should an emergency occur.

Rights and Responsibilities of the Provider and Patient 1) We will require that prior to prescription of any medication(s), a physical examination will need to be completed by patient's primary medical doctor. 2) We reserve the right to assess suitability and appropriateness of telepsychiatry 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. 4) 48-hours notice is required for all cancelations. The patient will not be refunded the appointment fee without proper notice.

1) The patient understands that he/she is consenting to behavioral health evaluation and treatment via telepsychiatry. 2) The patient understands that no results can be guaranteed, despite our best efforts to deliver care. 3) The patient understands that they are able to ask questions about telepsychiatry or any aspects of the evaluation and treatment at any time.

I certify that I have read and understand the entirety of this document, titled "Telepsychiatry Contract and Informed Consent." By signing below, I am agreeing with this document, put forward by Dr. Madeleine R. Eugene, DNP, AGNP-C, PMHNP-BC, and I am also authorizing Dr. Madeleine R. Eugene, DNP, AGNP-C, PMHNP-BC to use telepsychiatry for my evaluation and treatment.