Informed Consent for Telehealth Services
What is Telehealth/Telemedicine ?Telehealth is “the use of telecommunication and information technology to provide access to health assessment, diagnosis, intervention, consultation, supervision, and information across distance.” Telehealth is a means by which Four Peaks Neurology providers can diagnose, treat, consult, and educate using interactive audio, video, or data communication.
I hereby consent to participate in medical treatment, psychotherapy, and ABA therapy via electronic device with Four Peaks Neurology. I understand that telehealth services may be provided by a physician, nurse practitioner, or psychiatrist.
Potential Risks with Telehealth.
I understand that telehealth may not be appropriate for all patients, and that a face-to-face consultation may still be necessary. Four Peaks Neurology uses secured encrypted audio/video transmission software to deliver telehealth. In rare circumstances despite reasonable efforts on the part of Four Peaks Neurology, security protocols could fail causing a breach of patient privacy. The transmission of personal information could be unintentionally lost or accessed by unauthorized persons, and/or the electronic storage of my personal information could be unintentionally lost or accessed by unauthorized persons.
Alternative Treatment
Providers shall use their clinical discretion to determine whether telehealth services are appropriate. The alternative to telehealth consultation is a face-to-face visit with your provider.
Confidentiality
I understand that the laws that protect privacy and the confidentiality of medical information also apply to telehealth, and that no information obtained in the use of telehealth, which identifies me will be disclosed to researchers or other entities without my consent.
Audio/video recording, streaming, or capture of telehealth services is prohibited without written or verbal consent from the provider.
We may use health information about you to provide medical treatment or services. We may disclose your health information to doctors, nurses, technicians, office staff, or other personnel who are involved in your treatment. Personnel in our office may share information about you and disclose information to health care personnel who do not work in our office in order to coordinate care, such as phoning in prescriptions to your pharmacy and scheduling lab work. Family members and other health care providers may be part of your medical care outside this office and may require information about you that we have. We may leave messages at the numbers provided by you or with a family member unless we receive in writing a request not to receive such communications.
Others may also be present during the consultation other than my provider in order to operate the video equipment. The above-mentioned people will maintain confidentiality of the information obtained. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history that are personally sensitive to me, (2) ask non-clinical personnel to leave the telehealth room.
Mandatory Reporting
Any physician, nurse practitioner, psychiatrist, technician, healthcare worker, or counselor that has “reason to believe” that a child or adult have been subjected to abuse or neglect, including sexual abuse, are required by law to report this abuse and neglect as mandated reporters.
Medical Records
You have the right to inspect and copy your health information, such as medical and billing records, that we use to make decisions about your care. You must submit a written request to Four Peaks Neurology in order to inspect and/or copy your health information. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other associated supplies. We may deny your request to inspect and/or copy in certain limited circumstances.
If you are denied access to your health information, you may ask that the denial be reviewed. If such a review is required by law, we will select a licensed health care professional to review your request and our denial. The person conducting the review will not be the person who denied your request, and we will comply with the outcome of the review.
Rights
I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment.
Telehealth Recommendations for Patients
To protect your confidentiality and security of your information, we recommend the following:
- 1. Telehealth sessions should be held in a private location.
- 2. Use a private computer or phone.
- 3. Password protect any technology used to interact with your provider.
- 4. Hang up and log out of the session once it is completed.
- 5. If providers need to reach you via phone, they might use blocked phone numbers.
Payment for Telehealth Services
Four Peaks Neurology will bill insurance for telehealth services when these services have been determined to be covered by an individual’s insurance plan. Full insurance co-payments/co-insurance and/or deductible, as well as account balances are due at the time of service. Only credit cards will be accepted.
You are responsible for knowing what your insurance benefits are, including what your insurance will and will not pay for; and how to access your benefits, including obtaining referrals, etc. If you are unsure, please contact your insurance carrier. This office assumes no responsibility for your lack of knowledge regarding your insurance benefits. If insurance does not cover services provided, it is the responsibility of the patient or guarantor to pay any unpaid charges as determined by your insurance company. Private pay rates are available when individuals’ insurance carriers do not cover telehealth.
Cancellation
A scheduled appointment means that time is reserved for you. If an appointment is missed or cancelled for any reason, with less than 24 hours’ notice, the patient will be billed according to the scheduled fee. No show telehealth is $50. Cancellation/No show fees are generally not paid by insurance companies.
Consent to the Use of Telehealth
I have read and understand the information provided above regarding telehealth, have discussed it with my provider or such assistants, and all my questions have been answered to my satisfaction. I have read this document carefully and understand the risks and benefits related to the use of telehealth services and have had my questions regarding the procedure explained. I hereby give my informed consent to participate in the use of telehealth services for treatment under the terms outlined herein.
Four Peaks Neurology, P.C.
