CONSENT FOR TELEMENTAL HEALTH SERVICES
1. In light of COVID-19 precautions, my health care provider and I have mutually decided to engage in a telehealth consultation. Telemental health is a temporary service that is being offered due to extreme circumstances as a precautionary measure. When the crisis passes, therapy sessions will return to being in-person.
2. Video conferencing technology is not the same as a direct Patient/ Provider visit due to the fact the Psychiatrist and patients are not in the same room. Visual or auditory cues that are more apparent in-person may be missed in a video chat.
3. Confidentiality still applies for telemental health services, and nobody will record the session. However, you must make sure you are in a secure room where no one can hear your conversation and you can have minimal interruptions. Also, please use a secure internet connection rather than public/free Wi-Fi for your privacy.
4. As a Provider, I will also take every precaution to ensure technologically secure, HIPAA compliant, and environmentally private psychotherapy sessions. I cannot control the technology freezing, crashing, or bad connections, but I will work with you every way we can to ensure the best possible interactions.
5. A smartphone, webcam & audio enable equipment, laptop, the tablet will need to be enabled during the session. Headphones or earbuds may improve sound quality and increase your privacy. Some clients may choose to sit in their car for the session for the utmost privacy.
6. I understand that the privacy laws that protect the confidentiality of my protected health information (PHI) also apply to telemental health unless an exception to confidentiality applies (i.e. mandatory reporting of a child, elder, or vulnerable adult abuse; danger to self or others; I raise mental/emotional health as an issue in a legal proceeding, physical health danger).
7. I understand that Telemental health is not a substitute for crisis/emergency services, please call the crisis hotline 800-273-8255, For a life-threatening emergency, dial 911, or go directly to your local Mental Health hospital emergency room.
8. I understand that if I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms, or experiencing a mental health crisis that cannot be resolved remotely, it may be determined that telemental health services are not appropriate and a higher level of care is required. I understand that my Telemental health providers may need to contact my emergency contact and/or appropriate authorities in case of an emergency.
9. I understand that a telehealth consultation has potential benefits including easier access to care, less potential exposure to COVID-19, and the convenience of meeting from a location in Florida of my choosing.
10. I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation. This will not jeopardize my access to future care, services, and benefits. IN CASE OF TECHNOLOGY FAILURE If service is disrupted due to a tech failure, please phone us at 407 903 9696. We may choose to reschedule if there are problems with connectivity. STRUCTURE and COST OF THERAPY SESSIONS: Telemental health sessions are the same fees as face to face sessions. ($440 per session). It is the understanding of the provider that Telemental health sessions during the current COVID-19 outbreak may be covered the same as in-person a session with your insurance company. Prior to any session, please verify insurance status and coverage. Please contact your insurance to verify coverage via Telemental health before engaging in it so you are clear about what the cost will be to you. Payment is the responsibility of the Patient or guardian regardless of insurance reimbursement and is due at the time of service. RELEASE OF LIABILITY: I unconditionally release and discharge Syeda N. Sultana, M.D., Bay Hill Psychiatric Asssociates, LLC DBA Psychiatric Clinic.net, Providers, trainees, staffs, and employees, from any liability in connection with my participation in the remote consultations. By signing this form, I certify: • That I have read or had this form read and/or had this form explained to me. • That I fully understand its contents including the risks and benefits of the procedure(s). • That I have had a direct conversation with my staff of the provider, during which I had the opportunity to ask questions in regard to this procedure. My questions have been answered and the risks, benefits, and any practical alternatives have been discussed with me in a language in which I understand