TELEHEALTH INFORMED CONSENT FORM
236 W ALLEGHENY AVE
PHILADELPHIA, PA 19133-3629
215-989-1771
admin@alliedcomfortncare.com
PATIENT INFORMATION
Patient Name:
*
Date of Birth:
*
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Month
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Day
Year
Date
Phone Number:
*
Format: (000) 000-0000.
Email Address:
*
example@example.com
Date:
*
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Month
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Day
Year
Date
PATIENT RESPONSIBILITIES
I agree to:
Participate from a private and secure location whenever possible.
Protect the confidentiality of my telehealth session.
Provide accurate contact information.
Notify the provider if technical issues arise.
Inform the provider of my physical location at the beginning of each telehealth session.
Provide emergency contact information.
PURPOSE OF TELEHEALTH SERVICES
Telehealth is the delivery of healthcare services through secure electronic communications, including video conferencing, telephone communication, and other technology-assisted methods.
Allied Comfort & Care offers telehealth services to improve access to behavioral health care and support continuity of treatment.
EMERGENCY PROCEDURES
Telehealth is not intended for emergency services.
If I experience a mental health emergency, I will:
Call 911
Contact 988 Suicide & Crisis Lifeline
Go to the nearest emergency room
Contact local crisis intervention services
Emergency Contact Name:
Relationship:
Phone Number:
Format: (000) 000-0000.
SERVICES PROVIDED VIA TELEHEALTH
Telehealth services may include:
Telehealth services may include:
Psychiatric Evaluations
Medication Management
Individual Therapy
Family Therapy
Group Therapy
Follow-Up Appointments
Treatment Planning
Care Coordination
Other
TECHNOLOGY CONSENT
I understand that telehealth services may involve:
I understand that telehealth services may involve:
Video Conferencing
Secure Messaging
Telephone Sessions
Electronic Document Exchange
I acknowledge that technical problems may occur and may require rescheduling or alternative methods of communication.
PATIENT UNDERSTANDING
Benefits of Telehealth
Increased access to care
Reduced travel time and expenses
Improved continuity of treatment
Greater convenience and flexibility
Ability to receive services from home or another private location
FINANCIAL RESPONSIBILITY
I understand that telehealth services may be billed to my insurance carrier in the same manner as in-person services.
I understand that I am responsible for:
Copayments
Coinsurance
Deductibles
Non-covered services
I acknowledge that insurance coverage for telehealth services may vary by payer and plan.
Potential Risks
Technical failures or interruptions
Poor audio or video quality
Delays in treatment due to technology issues
Potential unauthorized access despite security safeguards
Limited ability to respond to emergencies remotely
CONFIDENTIALITY
Allied Comfort & Care uses secure technology to protect patient information.
I understand that:
Telehealth sessions are confidential.
Sessions will not be recorded without my written permission.
Electronic communications are protected in accordance with HIPAA and applicable Pennsylvartal laws.
Confidentiality may be disclosed only as permitted or required by law.
CONSENT TO TELEHEALTH SERVICES
I have read and understand this Telehealth Informed Consent Form. I have had the opportunity to ask questions and have received satisfactory answers. I voluntarily consent to receive behavioral health services through telehealth from Allied Comfort & Care Outpatient Mental Health Clinic. I understand that I may withdraw this consent at any time by notifying my provider in writing.
Exceptions include:
Threats of harm to self or others
Suspected abuse or neglect
Medical emergencies
Court orders or legal requirements
PATIENT ACKNOWLEDGMENT
Patient Signature:
*
Date:
*
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Month
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Day
Year
Date
Parent/Guardian Signature (if applicable):
Date:
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Month
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Day
Year
Date
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