I consent to engaging in telehealth with Minnesota Community Care as a part of my treatment goals. I understand that telehealth may include medical or mental health evaluation, assessment, consultation, treatment planning, and medications. Telehealth will occur primarily through interactive video communications.
By signing this consent, I am verifying I understand the following:
1. I have the right to withhold or remove consent for telehealth services at any time without affecting my right to future care or treatment, nor endangering the loss or withdrawal of any program benefits to which I would otherwise be eligible.
2. The laws that protect the confidentiality of my personal information also apply to telehealth. As such, I understand that the information released by me during the course of my visits is confidential, just as it would be if I were in the clinic. I understand that the visit is transmitted over dedicated lines and cannot be accessed by any unauthorized individuals.
3. I agree that certain situations including emergencies and crises are inappropriate for video/computer-based health services. If I am in crisis or in an emergency I should immediately call 911 or go to the nearest hospital or crisis facility. By signing this document, I acknowledge I have been told that if I feel suicidal I am to call 911, local county crisis agencies or the National Suicide Hotline at 1-800-784-2433. Similar to in person visits, if I share possible danger to myself or others, I understand that my provider is required to share this information for my safety and that of others.
4. I understand that payment for this visit will be the same as an in-person visit. I understand that my insurance be billed or Minnesota’s sliding scale fee will be applied.
5. My provider has explained to me how the telehealth technology will work. I have been given the opportunity to ask questions, all of which have been answered to my satisfaction.