Consent for Telehealth Treatment

Introduction

Telehealth involves the use of electronic communications to enable health care providers to provide patient care through the means of live two-way audio and/or video. The purpose of this form is to obtain your consent to participate in a Telehealth consultation for various medical conditions/illnesses. The information may be used for diagnosis, Treatment, therapy, follow-up and/or education, and may include any of the following: Patient medical records, Medical images, Live two-way audio and/or video and Output data from medical devices and sound and video files as well as secure messaging through our HIPAA compliant telehealth app.

Confidentiality

Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and ensure its integrity against intentional or unintentional corruption. Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with the Telehealth consultation and the software used by our office is HIPAA compliant. This means it meets appropriate requirements for patient privacy laws to keep your data as safe as possible.

Possible Risks

As with any medical procedure, there are potential risks associated with the use of Telehealth. These risks include, but may not be limited to: In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the provider. There are potential risks to this technology, including interruptions, unauthorized access and technical difficulties. The session may be discontinued and rescheduled by the provider if the video conference connection is not adequate for the situation. It is the patient or their parent/legal guardian's responsibility to ensure the patient has a reliable internet connection to use for appointments. We understand extreme weather may cause unforeseen issues.

Your Rights

Consent to telehealth is required to receive services at our practice at this time. You may withhold or withdraw consent to the Telehealth consultation at any time. You are not required to receive services from Boston Psychiatric Alliance and other appropriate services that do not require telehealth consent are available. If you do withhold or withdraw consent, this may require us to provide you with a referral to another provider outside our office who can better meet your needs.

Office Telehealth Policies

I understand that I cannot be operating a motor vehicle while engaging in telehealth at BPA If it is found I am operating a vehicle during the appointment the clinician will immediately close the appointment session. I may be charged a late cancel/missed appointment fee and asked to reschedule the appointment at a later time. I understand it is my obligation to be in a private location where I can speak openly about my health during my telehealth appointment. My clinician can not be held liable for information heard by others near me from my end of the call. I will only allow those that I feel comfortable hearing my private health information around me during my telehealth call. I agree to behave in a respectable manner that would resemble an appropriate in-person interaction in an office setting. I understand that any minor children must be accompanied by a parent or legal guardian during their appointment unless previously discussed with the clinician that they may attend a telehealth session alone.

By checking the above box, you are verifying you've read, understand and agree to all conditions indicated on this Telehealth consent form.

By typing your name above, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.