You must be a New York State resident or existing patient to participate in telemedicine services provided by Neighborhood Psychiatric Associates of Manhattan, PLLC d/b/a Neighborhood Psychiatry (“Neighborhood Psychiatry”) and any clinicians employed by or contracted with Neighborhood Psychiatry. If you are not an existing patient of Neighborhood Psychiatry, proof of residence must be provided prior to the commencement of any telemedicine services through valid New York State issued identification.
I hereby consent to engaging in telemedicine with Neighborhood Psychiatry, as part of my Psychiatry evaluations and medication management sessions. I understand that "telemedicine" includes the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, or data communications.
Electronically transmitted information may be used for diagnosis, treatment, follow-up, and/or patient education, and my include any of the following:
· Patient medical records;
· Medical images;
· Interactive audio, video and/or data communications; and/or
· Output data from medical devices, sound and video files
The interactive electronic systems used to incorporate network and software security protocols protect the confidentiality of patient information and my imaging data and includes measures to safeguard the data and to aid in protecting against intentional or unintentional corruption.
· Improving access to specialized medical care by enabling a patient to remain in his or her home while receiving professional care from a healthcare provider.
· More efficient medical evaluation and management.
· Assisting your local health service to better look after you.
As with any medical procedure, there may be potential risks associated with the use of telemedicine. These risks include, but may not be limited to:
· Information transmitted may not be sufficient (e.g., poor resolution of images) to allow for appropriate medical decision making by my physician.
· A physician may not be able to provide medical treatment to me using telemedicine equipment nor provide for or arrange for an emergency care that I may require.
· Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment.
· Security protocols could fail, causing a breach of privacy of my confidential medical information. This health care service uses systems that meet recommended standards to protect the privacy and security of the video visits. However, the service cannot guarantee total protection against hacking or tapping into the video visit by outsiders. This risk is small, but it does exist.
· A lack of access to complete medical records may result in errors in medical judgment.
By signing this form, I understand and agree to the following:
1. The laws that protect the confidentiality of my medical information also apply to telemedicine. As such, I understand that the information disclosed by me during the course of my therapy is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding. Information obtained during a telemedicine encounter, which identifies me, should not be disclosed to any third party without my consent except for the purposes of treatment, payment, and healthcare options.
2. I understand that I am responsible for the payment of co-pays, co-insurance, deductibles and all other procedures or treatment not covered by my insurance plan. In providing credit card information and signing below, I authorize Neighborhood Psychiatry to collect payment for any amounts due in the event that I have not paid at the time of service.
3. I also understand that the dissemination of any personally identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without my written consent.
4. I understand that other individuals other than my physician may be present and have access to my medical information during the consultation in order to operate the video equipment, should such equipment be utilized.
5.I understand that some parts of the exam involving physical tests may be conducted by individuals at my location at the direction of the physician.
6.I understand that there are risks and consequences from telemedicine, including, but not limited to, the possibility, despite reasonable efforts on the part of my psychiatrist, that: the transmission of my medical information could be disrupted or distorted by technical failures; the transmission of my medical information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons.
7. In addition, I understand that telemedicine based services and care may not be as complete as face-to-face services. I also understand that if my psychotherapist believes I would be better served by another form of psychiatric services (e.g. face-to-face services) I will be referred to a psychiatrist who can provide such services in my area. Finally, I understand that there are potential risks and benefits associated with any form of psychiatry, and that despite my efforts and the efforts of my psychiatrist, my condition may not be improve, and in some cases may even get worse.
8. I have the right to withhold or withdraw my consent to the use of telemedicine during the course of my care at any time. I understand that my withdrawal of consent will not affect my future care or treatment, nor will it subject me to the risk of loss or withdrawal of any health benefits to which I am otherwise entitled.
9. I have the right to inspect all information obtained and recorded during the course of a telemedicine interaction, and may receive copies of this information for a reasonable fee. Such inspection and copying of records shall be subject to my physician’s office policies and procedures.
10. I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed. My condition may not be cured or improved, and in some cases, may get worse.
11. I understand that my condition may require a referral to a specialist for further evaluation and treatment.
12. A variety of alternative methods of medical care may be available to me, and I may choose one or more of these at any time. My physician has explained the alternative care methods to my satisfaction.
13. I understand that I have a right to access my medical information and copies of medical records in accordance with New York Law.
14. NEIGHBORHOOD PSYCHIATRY PROVIDES THE SERVICES “AS IS” AND “AS AVAILABLE.” NEIGHBORHOOD PSYCHIATRY MAKES NO EXPRESS OR IMPLIED WARRANTIES OR GUARANTEES ABOUT THE SERVICES. TO THE MAXIMUM EXTENT PERMITTED BY LAW, NEIGHBORHOOD PSYCHIATRY HEREBY DISCLAIMS ALL SUCH WARRANTIES, INCLUDING ALL STATUTORY WARRANTIES, WITH RESPECT TO THE SERVICES, INCLUDING, WITHOUT LIMITATION, ANY WARRANTIES THAT THE SERVICES ARE MERCHANTABLE, OF SATISFACTORY QUALITY, ACCURATE, FIT FOR A PARTICULAR PURPOSE OR NEED, OR NON-INFRINGING. NEIGHBORHOOD PSYCHIATRY DOES NOT GUARANTEE THAT THE RESULTS THAT MAY BE OBTAINED FROM THE USE OF THE SERVICES WILL BE EFFECTIVE, RELIABLE OR ACCURATE OR WILL MEET MY REQUIREMENTS. NEIGHBORHOOD PSYCHIATRY DOES NOT GUARANTEE THAT I WILL BE ABLE TO ACCESS OR USE THE SERVICES (EITHER DIRECTLY OR THROUGH THIRD-PARTY NETWORKS) AT TIMES OR LOCATIONS OF MY CHOOSING. EXCEPT AS EXPRESSLY SET FORTH HEREIN, NEIGHBORHOOD PSYCHIATRY MAKES NO WARRANTIES ABOUT THE INFORMATION SYSTEMS, SOFTWARE AND FUNCTIONS MADE ACCESSIBLE THROUGH THE SERVICES OR ANY OTHER SECURITY ASSOCIATED WITH THE TRANSMISSION OF SENSITIVE INFORMATION.
15. IN NO EVENT SHALL NEIGHBORHOOD PSYCHIATRY BE LIABLE TO ME (OR TO ANY THIRD PARTY CLAIMING UNDER OR THROUGH ME) FOR ANY INDIRECT, SPECIAL, INCIDENTAL, CONSEQUENTIAL OR EXEMPLARY DAMAGES ARISING FROM MY USE OF, OR INABILITY TO USE, THE TELEMEDICINE SERVICES. THESE EXCLUSIONS APPLY TO ANY CLAIMS FOR LOST PROFITS, LOST DATA, LOSS OF GOODWILL, COMPUTER FAILURE OR MALFUNCTION, ANY OTHER COMMERCIAL DAMAGES OR LOSSES, OR MEDICAL MALPRACTICE OR NEGLIGENCE OF HEALTHCARE PROVIDERS UTILIZED THROUGH USE OF THE SERVICES, EVEN IF NEIGHBORHOOD PSYCHIATRY KNEW OR SHOULD HAVE KNOWN OF THE POSSIBILITY OF SUCH DAMAGES.
16. TELEMEDICINE IS NOT INTENDED FOR USE IN A MEDICAL EMERGENCY OR IN CASE OF AN URGENT HEALTHCARE NEED. IF YOU ARE EXPERIENCING A MEDICAL EMERGENCY, YOU SHOULD DIAL “911” IMMEDIATELY.
Patient Consent to the Use of Telemedicine
I have read and understand the information provided above regarding telemedicine, have discussed it with my physician and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telemedicine in the course of my diagnosis and treatment. This consent remains in effect until retracted or until 30 days after I discontinue care, whichever comes first.