Telehealth Consent

Telehealth is a type of care that allows clients to access behavioral health services using an audio-video interface, such as videoconferencing.

Electronic systems used will incorporate network and software security protocols to protect the confidentiality of client identification and imaging data. They will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

Expected Benefits

• Improved access to behavioral health care by enabling a client to receive services across distances and between programs.

• More efficient behavioral health care, including psychiatric evaluation and management.

• Obtaining the expertise of a distant specialist.

• Maintaining connections with established providers in other areas.

Possible Risks:

As with any medical procedure, there are potential risks associated with using telehealth for behavioral health treatment. 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 physician or other clinical staff.

• Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment.

• In rare instances, security protocols could fail, causing a breach of privacy of personal medical information.

• In rare cases, a lack of access to complete medical records may result in adverse drug interactions, allergic reactions, or other judgmental errors.

By consenting to these forms, I understand the following:

1. I understand that the laws that protect the privacy and confidentiality of medical information also apply to telehealth and that no information obtained in the use of telehealth that identifies me will be disclosed to researchers or other entities without my consent.

2. I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time without affecting my right to future care or treatment.

3. I understand that I have the right to inspect all information obtained and documented during a telehealth interaction and may receive copies of this information for a reasonable fee.

4. I understand that I may be offered a variety of alternative methods of behavioral health care and that I may choose one or more of these at any time.

5. I understand that it is in my best interest to inform my psychiatrist or other clinical staff of any other healthcare providers involved in my medical/psychiatric care.

6. I understand that I may expect the anticipated benefits from using telehealth in my care, but no results can be guaranteed or assured.

Client Consent to the Use of Telehealth Central

I have read and understood the information provided above regarding Telehealth Central, have discussed it with my psychiatrist or other clinical staff as may be designated, and have had all of my questions answered to my satisfaction. I hereby give my informed consent for the use of Telehealth Central in my behavioral health care. I have been offered a copy of this form for my personal records.

My continued use of the services constitutes my understanding and acceptance of the above terms, and I hereby authorize the use of Telehealth Central in the course of my diagnosis and treatment.

Complaints about Medical Professionals

If you have a concern about a medical professional, you may contact the Medical Board in your state regarding your concerns. For applicable contact information, see the list available here. Special Notice to California Clients. Physicians and midwives are licensed and regulated by the Medical Board of California.

To confirm a license or file a complaint, visit www.mbc.ca.gov or call (800) 633-2322. The California Board of Behavioral Sciences receives and responds to complaints regarding services provided within the scope of practice of marriage and family therapists, licensed educational psychologists, clinical social workers, and professional counselors. You may contact the Board of Behavioral Sciences at http://www.bbs.ca.gov or call (916) 574-7830.

HIPAA Consent

The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began on July 1, 2024.

This is all about the rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with services. HIPAA provides certain rights and protections to you as the customer. We at Telehealth Central meet these needs to provide you with quality professional service and care. Additional information, including the full list of HIPAA-required rights, is available here from the U.S. Department of Health and Human Services (hhhs.gov).

We have adopted the following policies:

1. Patient information will be kept confidential except as necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately.

   This specifically includes sharing information with other healthcare providers, laboratories, and health insurance payers as is necessary and appropriate for your care. Patient files may be stored in open file racks and will not contain any coding that identifies a patient’s condition or information that is not already a matter of public record.

   The normal course of providing care means that such records may be left, at least temporarily, in administrative areas such as the reception office, examination room, etc. Those records will not be available to persons other than office staff and third-party providers.

   You agree to the normal procedures utilized within the office for handling charts, patient records, PHI, and other documents or information.

2. T

   his office’s policy is to remind patients of their appointments. We may do this by telephone, e-mail, U.S. mail, or by any means convenient for the practice and/or as you requested. We may send you other communications about policy or procedure changes that you find valuable or informative.

3. The practice utilizes several vendors in conducting business. These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA.

4. You understand and agree to government agencies or insurance payers inspecting the office and reviewing documents that may include PHI in the normal performance of their duties.

5. You agree to bring any concerns or complaints regarding privacy to the attention of the office manager or the doctor.

6. Your confidential information will not be used for marketing or advertising products, goods, or services.

7. We agree to provide patients with access to their records in accordance with state and federal laws.

8. We may change, add, delete, or modify any of these provisions to better serve the needs of both the practice and the patient.

9. You have the right to request restrictions on using your protected health information and to request changes in certain office policies regarding your PHI. However, we are not obligated to alter internal policies to accommodate your request.

My continued use of the services constitutes my understanding and acceptance of the above terms outlined in the HIPAA INFORMATION FORM and any subsequent changes in office policy. I understand that this consent shall remain in force from this time forward.

Financial Consent

I understand and accept the terms to render services that a credit card must be kept on file and that any remaining Telehealth Central for services rendered shall be paid in full.

I authorize Telehealth Central LLC to submit on my behalf and the release of any medical records or other information necessary to process my consultation order. Fee schedules and receipts for all professional services are available upon request.

I authorize Telehealth Central LLC to make invoice changes and debit my account for orders placed, goods received, and/or services rendered not fully covered by third-party vouchers or credits.

I authorize Telehealth Central LLC to charge my credit card account upon any unpaid Telehealth Central bills due. All programs are auto-renewing, and I consent to be automatically charged for any program I am a part of unless I explicitly request to cancel before my payment is processed

There are no refunds or exchanges.

I certify that I am an authorized user of this credit card and that I will not dispute the payments with my credit card company.

Contact

For any questions about Medical Consent, please contact us.