Telehealth Consent Form
1. I authorize True Balance Ltd to allow me/the Client to participate in a Telehealth (videoconferencing) services.
2. The type of service to be provided by via Telehealth is: mental health counseling and psychiatric medication management.
3. I understand that this service is not the same as a direct Client /healthcare provider visit, because I will not be in the same room as the healthcare provider performing the service. I understand that parts of my care and treatment which require physical tests or examinations may be conducted by providers and their staff at my location under the direction of the Telehealth healthcare provider.
4. My provider or support staff have fully explained to me the nature and purpose of the videoconferencing technology and has also informed me of expected risks, benefits and complications (from known and unknown causes), attendant discomforts and risks that may arise during the Telehealth session, as well as possible alternatives to the proposed sessions, including visits with a provider in-person. The attendant risks of not using Telehealth sessions have also been discussed. I have been given an opportunity to ask questions, and all of my questions have been answered fully and satisfactorily.
5. I understand that there are potential risks to the use of this technology, including but not limited to interruptions, unauthorized access by third parties, and technical difficulties. I am aware that either my provider or I can discontinue the Telehealth service if we believe that the videoconferencing connections are not adequate for the situation.
6. I understand that the Telehealth session will not be audio or video recorded at any time. A transcript of the session may be attached to my medical file as needed.
7. I agree to permit my healthcare information to be shared with other individuals for the purpose of scheduling and billing. I agree to permit individuals other than my healthcare provider and the remote healthcare provider to be present during my Telehealth service to operate the video equipment, if necessary. I further understand that I will be informed of their presence during the Telehealth services. I acknowledge that if safety concerns mandate additional persons to be present, then my or guardian permission may not be needed.
8. I acknowledge that I have the right to request the following:
a. Asking non-medical personnel to leave the Telehealth room at any time if not mandated for safety concerns (including safety of self, space, or others), or
b. Termination of the service at any time.
9. When the Telehealth service is being used during an emergency, I understand that it is the responsibility of the Telehealth provider to advise my local healthcare provider regarding necessary care and treatment.
10. It is the responsibility of the Telehealth provider to conclude the service upon termination of the videoconference connection.
11. I understand(s) that my insurance will be billed by the provider. I understand(s) that if my insurance does not cover Telehealth services I will be billed directly and will be responsible for payment in full.
12. My consent to participate in this Telehealth service shall remain in effect for the duration of the specific service identified above, or until I revoke my consent in writing.
13. I agree that there have been no guarantees or assurances made about the results of this service.
14. I acknowledge the Telehealth program’s no-show policy which states that I will be discharged from the Telehealth program if I no-show for 2, consecutive Telehealth appointments, without prior contact to the scheduling staff.
15. I confirm that I have read and fully understand both the above and the Telehealth: What to Expect Form provided.