This Informed Consent form is intended to inform you about Heartland's policy and procedure regarding Telehealth Services and to ensure your agreement to these services. Your signature on this form indicates that you, the client, have acknowledged that you understand and agree that your Heartland clinician will provide therapy to you according to this Telehealth Informed Consent agreement. Please ensure that each section is read and reviewed carefully. If you have any questions, please discuss them with your therapist before obtaining any Telehealth services. This policy can be available at any time if requested.
I understand that Telehealth (also referred to as e-therapy, teletherapy, tele-mental health, virtual therapy or video therapy) is the use of HIPAA compliant electronic information and communication technologies (including video and audio technology) by a mental health provider to deliver services to an individual when they are located at a site that is different than their provider.
I understand that the Health Insurance Portability and Accountability Act (HIPAA) policies and laws that protect the privacy and confidentiality of my medical information also applies to Telehealth. My rights to confidentiality with Telehealth services are exactly the same as my rights for in-person therapy services.
There are also limits to confidentiality as dictated by law. These limits are outlined in Heartland's Terms of Care and Consent form, which is signed by all clients prior to treatment.
Therapeutic treatment for mental health, both in person and through Telehealth services, has been found to be effective in treating a wide range of clients, though, individual results and responses to Telehealth may vary. By signing this form, I also understand that results of Teletherapy cannot be guaranteed.
I further understand that there are risks unique and specific to Telehealth, including but not limited to the possibility that our therapy sessions or other communication by my therapist to others regarding my treatment could be disrupted or distorted by technical failures, could be interrupted, or could be accessed by unauthorized persons. If a disruption or an emergency situation occurs, please contact
Heartland at 515-331-0303 for assistance.
I understand that Telehealth treatment for mental health is different from in-person therapy. I understand that if my therapist believes I would be better served by another form of therapeutic treatment or services, such as in-person treatment, I will be provided a referral to another therapist who can provide me with recommended services, such as in person therapy.
Additionally, I understand that the capture (including screenshots or photos of the therapy session), saving, or dissemination of any personally identifiable images or information from the Telehealth interaction to any other entities shall not occur without my explicit written consent. Heartland