When using my medical insurance as payment for TeleHealth Services (video or phone therapy), I understand that it is my responsibility to contact my insurance company before the first session to verify coverage forTeleHealth Services. (See Insurance Guidance, Form 1 at https://relationshiprediscoverycenter.com/forms ) I understand that I am responsible to pay the fees not covered by my insurance.
This form and any other documents containing confidential information are to be exchanged only by HIPA compliant, secure means including; fax 239-345-9743 or mail Relationship ReDiscovery Center, 444 Main St, Lewiston, ME 04240 or through a HIPA compliant electronic method if available.
I understand that these video sessions will be transmitted over HIPA compliant software as provided by Relationship ReDiscovery Center.
I understand that it is my responsibility to supply my own needed technology; cell phones, tablets, laptops, and or desktops computer. I understand that I am responsible for the security of all my electronic devises and related data, including any digital copies of any documents stored on my electronic devises.
I understand I am responsible for my data services charges that may occur. These charges may be avoided by using a secure wifi connection. When using Wifi, I understand that it is my responsibly to use only secure password protected wifi connections and not use unprotected public wifi.
I understand there are risk associated with video and phone therapy, including, but not limited to, disruption of transmission by technology failures, interruptions and /or breaches of confidentiality by unauthorized persons.
I understand that there will be no uninformed recording of any session by myself or my counselor. I may give my counselor permission to record session for educational and training purposes by signing a separate consent which I can retract at any time.
I understand that all policies as outlined in the Relationship ReDiscovery Center Disclosure Statement also apply to Video and phone sessions.
I agree to participate in TeleHealth sessions while dressed as if I were in public.
I agree to not participate in TeleHealth sessions while driving or while under the influences of substances.
I understand that TeleHealth sessions may not be appropriate in situations of high need; In such cases, referrals to more appropriate services will be provided.
I understand that in cases of emergency, my counselor will need to know my present location. At the start of each session I agree to inform my therapist of my current location. I understand that if I present with an emergency; serious suicidal or homicidal thoughts or other high risk, life threatening concern, my counselor may request assistance from my emergency contacts and or local authorities.
My signature below indicates that I have read and understand the above and give my consent to participate in TeleHealth services.