I hereby consent to telehealth services (“Telehealth”) with Alivation Health, LLC (“Alivation”). Telehealth may include health evaluations and assessments, consultations, treatment planning, education, and therapy. Telehealth will occur primarily through interactive audio, video, telephone, or other data communications.
Insurance: I am responsible for contacting my insurance company, if applicable, to determine what my out-of-pockets costs may be. I authorize insurance benefits to be paid directly to Alivation that Alivation may release any information to my insurance provider required for processing my claims.
Self-Pay clients: I am aware of the fees associated with Telehealth appointments and agree to pay at the time of my appointment. I understand that I am responsible for cancelled Telehealth appointments in accordance with the Alivation cancellation policy. In addition, I understand that:
· I must be in compliance with the Alivation provider's treatment plan.
· To receive telehealth services, I must be at an “originating site” acceptable to Alivation.
· Telehealth will not be allowed for opioid recovery and treatment.
· If access for Telehealth is from my computer or mobile device, I may need to download an application or software to use Telehealth and a broadband Internet computer or mobile device with a good cellular connection.
· Alivation has self-pay options if my insurance does not cover the telehealth visit.
· All other Alivation policies are applicable to Telehealth Visits.
· Patients are instructed to verify all equipment prior and log-on to the most up-to-date clinic Telehealth application at least 15 minutes prior to their appointment time.
· The patient understands and agrees to that any issues arising in utilizing the Telehealth platform, including but not limited to technical issues, connection issues, and usage issues in any capacity may result in the appointment not transpiring at the scheduled time and needing to be rescheduled, including to another date and time.
· Any appointment that is not able to be successfully completed to clinic standards is subject to all other clinic policies, including but not limited to, no-show fees, dismissal and loss of Telehealth privileges.
· Alivation continues to prefer and recommend all visits be completed in-person due to the factors cited above.
Disclosures. I understand I have the following rights:
1) I have the right to withhold or remove consent to Telehealth at any time without affecting my right to future care or treatment, nor endangering the loss or withdrawal of any program benefits to which I would otherwise be eligible.
2) The HIPAA laws that protect the confidentiality of my personal information also apply to Telehealth. The information released by me during the course of my sessions is generally confidential, but there are both mandatory and permissive exceptions to HIPAA confidentiality including but not limited to reporting child and vulnerable adult abuse, expressed imminent harm to oneself or others, or as a part of legal proceedings where information is requested by a court of law. Alivation has provided to me, including online disclosure, its Notice of Privacy Practices.
3) I understand that there are risks and consequences from Telehealth including the possibility, despite reasonable efforts on the part of Alivation that the transmission of my personal information could be disrupted or distorted by technical failures.
4) I understand that Telehealth based care may not be as complete as in-person services. I understand that if my therapist believes I would be bettered served by other interventions I will be referred to a mental health professional who can provide those services in person
5) I understand that the use of Telehealth services is not 100% secure and may have issues with Wi-Fi and network connectivity.
6) All reasonable attempts to keep information confidential while using Telehealth will be made but a guarantee of 100% confidentiality cannot be made with any inherent service.
7) By signing this document, I agree that certain situations, including emergencies and crises, are inappropriate for audio/video/computer-based psychotherapy services. If I am in crisis or in an emergency, I should immediately call 911 or go to the nearest hospital or crisis facility. By signing this document, I understand that emergency situations may include thoughts about hurting or harming myself or others, having uncontrolled psychotic symptoms, if I am in a life threating or emergency situation, and/or if I am abusing drugs or alcohol and are not safe. By signing this document, I acknowledge I have been told that if I feel suicidal I can to call 911, local county crisis agencies, or the National Suicide Hotline at 1-800-784-2433.
8) Others may also be present during the consultation other than my counselor in order to operate the video equipment. The above-mentioned people will all maintain confidentiality of the information obtained. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history that are personally sensitive to me, (2) ask non-clinical personnel to leave the Telehealth room, and/or (3) terminate the consultation at any time.