Fill the form below. 

 

I hereby consent to engaging in telemedicine at Lighthouse Health Group.  I understand that “telemedicine” and teletherapy includes the practice healthcare delivery, assessment, diagnosis, consultation, treatment, transfer of medical data, using interactive audio, video or data communications.  I understand that, with my signed consent, telemedicine may also involve the communication of my mental health information, both orally and visually, to other health care practitioners located in Florida.

Technology: I understand that Lighthouse Health Group is currently using Zoom for the platform.  I also need to have internet connection or a smart phone with data at home or the location I deem appropriate for services.  I also understand that in case of technology failure, I may contact Lighthouse Health Group to coordinate alternative method of treatment.

Financial Obligations: I am aware of the fees associated with telemedicine appointments and are payable by credit card only.  My card will be billed at the time of scheduled session. If my card is declined, Lighthouse Health Group will cancel my appointment and I will be charged in accordance with cancelation policy.

Scheduling: I understand that scheduling is conducted through Lighthouse Health Group and is based on normal operating hours.  Telemedicine appointments are not intended for emergency or crisis services. Crisis or Mental Health emergencies should be directed to the local county crisis line or by dialing 911. 

Video/ Audio Recording: As a general practice Lighthouse Health Group does not record telemedicine sessions.

Confidentiality: The laws that protect the confidentiality of medical information also apply to telemedicine.  As such, I understand that the information disclosed by me during my therapy is 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 towards an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding.  Lighthouse Health Group telemedicine platform is HIPAA compliant to protect my privacy and confidentiality.  This is further explained in the HIPAA “right to your information form.”

I understand that I have the following rights with respect to telemedicine:

I have the right to withdraw my consent at any time.
I understand that there are risks and consequences associated with telemedicine including but not limited to the possibility, despite reasonable efforts on the part of my provider that the transmission of
my medical information could be disrupted or distorted by technical failures.  In addition, I understand that telemedicine-based services and care may not be as complete as a face to face services.
I understand that I may benefit from telemedicine but that results cannot be guaranteed or assured.
I understand that Lighthouse Health Group may not provide telemedicine services to me if I am outside of Florida, and I understand that I may access telemedicine services from Lighthouse Health Group, from within the state of Florida only.
I understand that I have a right to access my mental health information and copies of medical records in accordance with Florida State law.
 

I have read and understand the information that has been provided above. I have discussed it with my provider and all of my questions have been answered to my satisfaction.  My signature below indicated my informed and willful consent to treatment using this platform.