1. I hereby authorize Hampton Mental Health Associates to use the telehealth practice platform for telecommunication for evaluating, testing, diagnosing and treatment of my mental health condition.
2. I understand that technical difficulties may occur before or during the telehealth sessions and my appointment cannot be started or ended as intended.
3. I understand that I am to observe telehealth etiquette during my appointment with my provider to include the following:
Pleae be on WIFI connection (not data/cell service
Have Zoom already downloaded, if you are unsure how to do this
contact the front des
Be seated in a private, quiet, well
t location. Please do not attempt to have your appointment in a
public space. If this occurs, your provider may ask that you reschedule your appointment for a different
Sign into the meeting 5
10 minutes prior to your appointment time. Your provide
r may be a few minutes
behind, but they will be with you shortly
Be appropriately dressed and sitting. Treat this appointment as if you were coming into the office
Make sure your video camera, microphone AND speaker are turned o
4. I accept that the professionals can contact interactive sessions with video call; however, I am informed that the sessions can be conducted via regular voice communication if the technical requirements such as internet speed cannot be met. I understand that in the future, the voice communications may not be allowed depending on the rules of Medicaid, Medicare, and commercial insurance companies and at that time, I will be required to participate in teleconference calls or come into the office for an in person visit.
5. I understand that my current insurance may not cover the additional fees of the telehealth practices and I may be responsible for any fee that my insurance company does not cover.
6. I agree that my medical records on telehealth can be kept for further evaluation, analysis and documentation, and in all of these, my information will be kept private.
My signature below attests that I am the patient or the patient’s personal representative signing this form and my agreement with the terms and conditions.