ABC Counseling, LLC
TELE-HEALTH INFORMED CONSENT AND AGREEMENT
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. Effective 3/22/2020
What is “Tele-Health? “Tele-Health”, also referred to as telemedicine and tele-therapy, is the practice and delivery of medical, mental or behavioral health treatment by a licensed provider where client/patient care, treatment, and/or services are provided through the use of real-time electronic communications in which the provider is located at a physical site that differs from the client/patient or recipient of those services.
Risks to Confidentiality, the laws that protect confidentiality of medical and mental health information disclosed between a provider and client/patient also apply to tele-heath. As such, all information transmitted via electronic means will be treated as confidential, except in the event of credible of harm to self or others and reports of child and/or elder abuse.
Risk to confidentiality as a result of participating in tele-health include disruption or distortion of transmitted communications due to technical failures, information interceptions by unauthorized persons, environmental barriers such as loud noises and/or lighting issues that occur outside of the provider’s control, and technical difficulties due to operator error. Although risks exist, the provider agrees to make every effort to minimize risks, as well as have alternate plans for conducting sessions when technical barriers are present.
By signing this consent, you are hereby agreeing to the following terms and acknowledgements:
*I understand that tele-therapy/tele-health is the use of electronic information and communication technologies by a health care provider to deliver services to an individual when he/she is located at a different site than the provider; and I further give consent to participating in and receiving tele-health services from [Select Counselor at the Bottom of the Page] my ABC Counselor.
*I understand that there are risks associated with participating in tele-health/tele-therapy including, but not limited to, the possibility, despite reasonable efforts on the part of my provider, that: transmission of PHI could be disrupted or distorted by technical failures, the transmission could be intercepted by unauthorized persons and client’s environmental factors may limited the effectiveness of treatment due to noise, lighting or lack of privacy.
*I understand that the laws that protect privacy and the confidentiality of medical information also applies to tele-health. If a third-party (i.e. insurance company or EAP organization) assumes financial responsibility for mental and/or behavioral health services provided, the third-party payor will have access to confidential Personal Health Information (PHI) as outlined in the Practice Policies.
*I understand that it is my responsibility to ensure that tele-health is covered by my insurance policy or Employee Assistance Program authorization, and I am responsible for any co-payments, co-insurances and non-covered charges. I also agree to have a credit/debit card on file in order to process payments electronically.
*I understand that if the provider deems it clinically appropriate for mental or behavioral health services to be rendered in-person, due to repeated technical failures, severity of symptoms or other risk factors, a referral will be made to a provider in my area or arrangements will be made for me to be seen by [Select Counselor at the Bottom of the Page] at ABC Counseling LLC in the Rockledge, Florida.
*I understand that I have the right to withhold or withdraw my consent to the use of tele-health/telemedicine in the course of my care at any time, without affecting my right to future care or treatment. I may revoke my consent verbally or in writing at any time by contacting my counselor at (321) 446-2113. As long as this consent is in force, my counselor may provide health care services to me via tele-health/telemedicine without the need for me to sign another consent form
For additional information regarding tele-health/telemedicine, please see FL Admin Code 59G-1.057