Authorization to Provide Services
I authorize the Northwestern Mental Health Center, Inc. and its employees to provide me, my dependent or other person for whom I am authorized to sign with eligible services. I agree to participate in the crisis response services that includes assessment, intervention and/or stabilization.

I understand that the crisis response services that I receive may be in-person or via, telemedicine. I understand that telemedicine services and/or video conferencing involve the communication of my medical information both orally and/or visually.

Authorization to Use and/or Disclose Protected Health Information
I understand that NWMHC has the right to obtain Protected Health Information about me from other agencies and individuals and to disclose Protected Health Information about me to other agencies and individuals if in its professional judgement it is believed that I am at risk of harming myself and/or others.

Once any crisis/emergency situation has passed, this document will not be used to seek and/or disclose Protected Health Information in support of any ongoing care that I may receive from NWMHC.

Rights with Respect to Telemedicine/Telephonic Services
Access to Information. I have the right to inspect all medical information that includes the telemedicine service and/or video conferencing visit. I may obtain copies of this medical record information for a reasonable fee.

Confidentiality. I understand that the laws which protect the confidentiality of medical information apply to telemedicine services and/or video conferencing. My visit will not be recorded and all identifying information in the interaction will be kept secure in the same manner as any other private medical information.

Potential Risks. I understand that there are risks from telemedicine service and/or video conferencing. These risks include, but are not limited to, the possibility (despite our best efforts to prevent this) that the transmission of medical information could be disrupted or distorted by technical failures in transmission.

I also understand that the electronic transmission of medical information could be interrupted or even accessed illegally by unauthorized persons.

Benefits. I understand that I can expect benefits from telemedicine services and/or video conferencing, but that no results can be guaranteed or assured. Telemedicine or video conferencing provides me with access to mental health care that otherwise would not have been available in my community.