Telehealth Consent
I agree to participate in Telehealth services offered through Transformations Health Services, LLC. including outpatient therapy and medication management. I understand that I have the option to schedule appointments with Transformations Health Services, LLC, Psychiatrist, Medical Psychologist, Psychiatric Nurse Practitioner, or Outpatient Therapist in another Transformations Health Services, LLC office that supports an on-site practitioner. However, such a face-to-face appointment may require a wait time from one to 4 weeks and commuting from out of town will be at my own expense. By signing below, I acknowledge that:
Eligibility:
Service recipients must meet traditional eligibility services for requirements as determined by prevailing state, MCO or third-party insurance practice guidelines. In addition, the person served must be willing, able, and have the equipment and internet connection to use telehealth services.
Equipment:
Prior to the delivery of services and throughout services the agency will determine if the person-served and the assigned staff have the necessary equipment and internet access to use telehealth at their respective locations.
Privacy:
Prior to the start of each session all staff in the session will identify themselves to the person served. A company ID should be displayed to verify the staff identity.
Prior to the start of each session all persons served and any other persons in attendance in the session will identify themselves to the staff. Staff may verify the person served’ s identity by comparing to a photograph on record or asking to see a personal ID. The person served may vouch for others.
The staff will ask the person served to pan the camera around the persons served’ s location. If others are present the staff will ask the person served if any others in attendance are permitted to be in the session. If not, the session will be rescheduled.
People served will be advised to use headset/ear buds. The staff must be in a private space to ensure conversations are private.
Emergency Procedures:
If applicable, the staff providing telehealth will become familiar with the emergency procedures of the remote site, if the procedures exist. For example: the fire evacuation procedure of an assisting living facility. Staff providing telehealth services will have access to the persons served’ s emergency contacts and crisis/safety plan when providing telehealth services.
If the telehealth service is not provided at a street address the staff will obtain a descriptor of the person served’ s location in case of emergency. For example, at the ABC Park in Anytown, KY at the bench by the main entrance. Staff providing telehealth services will have access to the persons served’ s local emergency resources, including phone numbers.