Telehealth is healthcare provided by any means other than a face-to-face visit. In telehealth services, medical and mental health information is used for diagnosis, consultation, treatment, therapy, follow-up, and education. Health information is exchanged interactively from one site to another through electronic communications. Telephone consultation, videoconferencing, transmission of still images, e-health technologies, patient portals, are all considered telehealth services.
I understand that telehealth involves the communication of my behavioral health information in an electronic or technology-assisted format.
I understand that I may opt out of the telehealth visit at any time. This will not change myability to receive future care at this office.
I understand that telehealth billing information is collected in the same manner as a regular office visit. My financial responsibility will be determined individually and governed by my insurance carrier(s), Medicare, or Medicaid, and it is my responsibility to check with my insurance plan to determine coverage.
I understand that all electronic medical communications carry some level of risk. While the likelihood of risks associated with the use of telehealth in a secure environment isreduced, the risks are nonetheless real and important to understand. These risks include but are not limited to:
•It is easier for electronic communication to be forwarded, intercepted, or even changed without my knowledge and despite taking reasonable measures.
•Electronic systems that are accessed by employers, friends, or others are not secure and should be avoided. It is important for me to use a secure network.
•Despite reasonable efforts on the part of my healthcare provider, the transmission of medical information could be disrupted or distorted by technical failures.
I agree that information exchanged during my telehealth visit will be maintained by Nike Carli, LCSW-R
I understand that I must take reasonable steps to protect myself from unauthorized use of my electronic communications by others.
The healthcare provider is not responsible for breaches of confidentiality caused by an independent third party or by me.
I understand that electronic communication cannot be used for emergencies or time-sensitive matters.
To the extent permitted by law, I agree to waive and release my healthcare provider and her practice from any claims I may have about the telehealth visit.