Psychiatrists are governed by a code of ethics and by various laws and regulations. Treatment is strictly voluntary and you may choose to discontinue treatment any time you wish. Therapy sessions between a psychiatrist and their patients are strictly confidential except under certain legally defined situations involving threats of self-harm, harm to others, and cases of past or present child abuse, elder abuse, or abuse of individuals. In those cases, psychiatrists are required by law to notify the proper authorities.
Telemedicine involves the use of electronic communication to enable a physician at a different location to share individual patient medical information for the purpose of improving patient care. The information may be used for diagnosis, therapy, follow-up, medication management, and may include any/all of the following during the telemedicine visit:
- Patient medical records
- Medical images
- Live two-way audio and video and/or photo or video
- Output data from medical devices
- Sound and audio files
Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption. There are potential risks associated with telemedicine including:
- Interruptions, unauthorized access, and technical difficulties/deficiencies of the equipment which may rarely lead to a breach of privacy of personal medical information or a delay in evaluation/treatment
- Sharing healthcare information for the purposes of scheduling and billing
- Others may be present for the purposes of operating the video equipment. All such personnel are mandated to protect your privacy and confidentiality. If another staff member will be in the room, you will be notified in advance and you will have the right to request that they leave or for the visit to be terminated
- I understand that some parts of a neurological exam may have to be conducted at an in-person appointment with a local physician or consulting health care practitioner
By signing this form, I consent and authorize Lifetime Insight and their staff to provide me services that include psychotherapy, medication management, laboratory tests, diagnostic procedures, and other appropriate alternative therapies; and that these services will be rendered through the use of telemedicine or in-person, as described.
- I have the right to be informed of and participate in the selection of treatment modalities, receive a copy of this consent, and withdraw this consent at any time
- I understand that no guarantees have or will be made to me as to the results of treatments or examinations
- I understand the alternatives to a telemedicine consultation and I choose to participate in telemedicine
- I understand that my obligation to pay the physician is not related to the success of the treatment accorded to the patient by the physician
- I understand that the laws to protect privacy and the confidentiality of medical information also apply to telemedicine
- In an emergency, I understand that the responsibility of the telemedicine physician is to advise your local practitioner
- I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time
I am also aware that I should ask the physician any question that I may have about my diagnosis, treatment, risks, or complications, alternative forms of treatments, and/or anticipated results of treatment. This consent remains valid until I choose to discontinue treatment.