TELEHEALTH TREATMENT INFORMED CONSENT

WASHINGTON SCHOOL OF PSYCHIATRY 

EUGENE MEYER TREATMENT CENTER

TELEHEALTH INFOMED CONSENT


INTRODUCTION:

Telehealth involves the use of electronic communications to enable health care providers at different locations to share individual patient medical information for the purpose of improving patient care. The information may be used for diagnosis, therapy, follow-up and/or education. 


Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption as required by law. 


INFORMED CONSENT

Telemedicine allows the clinician to diagnose, consult, treat, and educate using interactive audio-video communication.  I hereby consent to participating in psychotherapy and/or psychiatric treatment via audio-video communication.


I UNDERSTAND THE FOLLOWING: 


I have a right to confidentiality with Telehealth under the same laws that protect the confidentiality of my medical information for in-person psychotherapy and/or psychiatric treatment.  Any information disclosed during the course of my therapy, therefore, is generally confidential.  


I understand that there are exceptions to the confidential communication as required by law.  I understand that if I am in such a mental or emotional condition to be a danger to myself or others, my clinician has a right to break confidentiality to prevent the threatened danger. My clinician and I will establish an emergency plan and protocol for contact between sessions.


I understand that there are risks unique and specific to Telehealth, including the possibility that our session or other communications could be disrupted or distorted by technical failures. 


I understand that Telehealth sessions is different from in-person sessions and that if my clinician believes I would be better served by another form of psychotherapeutic services, it may be recommended that I come into the office or seek an alternative form of treatment.


I understand that I am responsible and not my insurance company for co-payments, coinsurance, and deductibles.  I am responsible for services not covered by my insurance company.  It is recommended that I contact. my insurance company to confirm in writing that they will cover telehealth service. Cost of services not covered are my responsibility.


ATTESTATION:

I have read and understand the information provided above regarding telehealth and hereby give my informed consent for the use of telemedicine in my medical care. 


I hereby authorize the Meyer Treatment Center to use telemedicine in the course of my diagnosis and treatment. 



CONSENT TO TREATMENT

Please click below if you wish to be treated by a clinician at the Meyer Treatment Center via Telehealth.  Questions? Please contact your therapist directly or contact the main office.