RBH TeleHealth Consent Form

Please correct the errors described below.

As a client of Rainier Behavioral Health, I understand it is possible that at some point in my treatment, services will be provided via Telehealth, as described below. I understand and agree to the following with respect to use of Rainier Behavioral Health’s Telehealth services: 1. I understand that Telehealth is health/mental health services provided by Rainier Behavioral Health via interactive audio and video technology while the provider is at a different location than me. Telehealth may be provided by Rainier Behavioral Health’s physicians, psychiatrists, psychologists, social workers, or other licensed professionals. 2. I understand that these Telehealth services may involve the communication of my health information, orally and visually. Specifically, I understand that Telehealth services include, but are not limited to, consultation, treatment, and transfer of health data using interactive audio and video. The laws that protect the confidentiality of my health information apply to these services the same as in-person services. As such, I understand that the information disclosed by me during any Telehealth session is confidential. However, there are both mandatory and permissive exceptions to confidentiality. 3. I understand that there are risks and consequences of using these services including, but not limited to, the possibility that, despite Rainier Behavioral Health’s reasonable efforts, the transmission of my health information could be disrupted or distorted by technical failures. I agree that Telehealth is appropriate for my circumstances despite these risks. I understand that when I receive Telehealth services from a location other than at Rainier Behavioral Health, my own device and internet connectivity may impact the quality of the services and that Rainier Behavioral Health does not have control over my end of the transmission. 4. I understand that Telehealth services may not be the same as in-person services, where non-verbal communication (body signals) are readily available to both provider and client. I have read and understand the information provided above. I hereby consent to participate in Telehealth services under the terms described above.

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