CONSENT FOR TELEHEALTH COUNSELING SESSIONS
- I understand that The Center for Living Balance, INC wishes me to engage in telehealth counseling sessions. My health care provider explained to me how the video conferencing technology that will be used to affect such a consultation will not be the same as a direct client/health care provider visit due to the fact that I will not be in the same room as my provider.
- I understand that a telehealth consultation has potential benefits including easier access to care and the convenience of meeting from a location of my choosing.
- I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties.
- I understand that my healthcare provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.
- I have had a direct conversation with my provider, during which I had the opportunity to ask questions in regard to this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.
CONSENT TO USE THE TELEHEALTH BY ZOOM SERVICE
Telehealth by ZOOM is the technology service we will use to conduct telehealth video conferencing appointments. It is simple to use and there are no passwords required to log in. By signing this document, I acknowledge:
- Telehealth by ZOOM is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911.
- Though my provider and I may be in direct, virtual contact through the Zoom, neither ZOOM nor the Telehealth Service provides any medical or healthcare services or advice including, but not limited to, emergency or urgent medical services. The Telehealth by ZOOM Service facilitates videoconferencing and is not responsible for the delivery of any healthcare, medical advice or care.
- I do not assume that my provider has access to any or all of the technical information in the Telehealth by ZOOM Service – or that such information is current, accurate or up-to-date. I will not rely on my health care provider to have any of this information in the Telehealth by ZOOM Service.
- To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment.
- Confidentiality still applies for telepsychology services and nobody will record the session without my explicit permission.
- To maintain confidentiality, I will not allow any additional, unauthorized participants into the session.
- We need a safety plan that includes at least one emergency contact and the closest ER to your physical location.
- My therapist and I will develop a back-up plan (e.g., phone number where I can be reached) to restart the session or to reschedule it in the event of technical problems.
- If I am seeking reimbursement from my insurance company, it is my responsibility to confirm with my insurance company that the video sessions will be reimbursed. If they are not reimbursed, I am still responsible for full payment.