Consent For Telehealth

 I understand that I have the rights with respect to telehealth:

1. The laws that protect the confidentiality of my personal information also apply to telehealth. As such, I understand that the information disclosed by me during the course of my sessions is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to, reporting child, elder, and dependent adult abuse; expressed threats of violence toward an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding. I also understand that the dissemination of any personally identifiable images or information from the telehealth interaction to other entities shall not occur without my written 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 there are risks and consequences inherent in the use of telehealth, including, but not limited to, the possibility, despite reasonable efforts on the part of the counselor, that: the transmission of my personal information could be disrupted or distorted by technical failures and the transmission of my personal information could be interrupted by unauthorized persons. CRS utilizes secure, encrypted audio/video transmission software to deliver telehealth which is intended to prevent any unauthorized persons.
4. I understand the alternatives to counseling through telehealth as they have been explained to me, and in choosing to participate in telehealth, I am agreeing to participate using audio/video conferencing technology. I also understand that at my request or at the direction of my counselor, I may be directed to “face-to- face” psychotherapy.
5. I understand that I may expect the anticipated benefits such as improved access to care and more efficient evaluation and management from the use of telehealth in my care, but that no results can be guaranteed or assured.
6. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. The above-mentioned people will all maintain confidentiality of the information obtained.
7. I understand that my express consent is required to forward my personally identifiable information to a third party. Examples include, but are not limited to, coordination of care with primary care physician, specialists, and other service providers who may be involved in my treatment.
8. I understand that I have a right to access my medical information and copies of my medical records in accordance with the laws pertaining to the state in which I reside.
9. By signing this document, I agree that certain situations, including emergencies and crises, are inappropriate for audio-/video-/computer-based psychotherapy services. If I am in crisis or in an emergency, I should immediately call 9-1-1 or seek help from a hospital or call 988 or crisis-oriented health care facility in my immediate area.
10. I understand that different states and different insurance companies have different regulations for the use of telehealth.

By checking acceptance as my signature below, I hereby state that I have read, understood, and agree to the terms of this document.

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