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Counseling Connections 2016

Telemental Health Informed Consent

As a client receiving behavioral services through telehealth methods, I understand:

elemental health is the delivery of behavioral health services using interactive technologies

(audio, video or other electronic communications) between a provider and a client that are not in

the same physical location. The interactive technologies used in Telemental health incorporate

network and software security protocols to protect the confidentiality of patient information

transmitted via any electronic channel. These protocols include measures to safeguard the data

and to aid in protecting against intentional or unintentional corruption. Electronic systems used

will incorporate network and software security protocols to protect the privacy and security of

health information and imaging data, and will include measures to safeguard the data to ensure

its integrity against intentional or unintentional corruption.

1. T

his service is provided by technology (included but not limited to video, phone, text

and

ail) and may involve direct face to face communication. There are benefits and

limitations to this service. I will need access to, and familiarity with, the appropriate

technology in order to participate in the service provided. The exchange of informati

ill not be direct and any paperwork exchanged will likely be provided through electronic

means or through postal delivery. During your virtual care consultation, details of your

medical history and personal health information may be discussed with you or your

behavioral health care professionals through the use of interactive video, audio or other

telecommunications technology.

2. I

f a need for direct, face to face services arises, it is my responsibility to contact

practitioners in my area such as _____________________, _____________________,

or ____________________ or to contact my behavioral health practitioner’s office for

ace to face appointment or my primary care provider if my behavioral health practitioner

is unavailable. I understand that an opening may not be immediately available in either

office.

3. I

may decline any telehealth services at any time without jeopardizing my access t

uture care, services or benefits.

4. T

hese services rely on technology, which allows for greater convenience in servic

del

ivery. There are risks in transmitting information over technology that include, but ar

not limited to, breaches of confidentiality, theft of personal information, and disruption of

service due to technical difficulties. My practitioner and I will regularly reassess t

appr

opriateness of continuing to deliver services to me through the use of t

echnologies we have agreed upon today, and modify our plan as needed.

5. I

n emergencies, in the event of disruption of services, or for routine or administrativ

reasons, it may be necessary to communicate by other means:

a. I

n emergency situations: _______________________________________________

b. Service disruption: ___________________________________________________

c. For other communication: ______________________________________________

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6. My practitioner may utilize alternative means of communication in the following

circumstances: video connections fail or phone line access is disrupted.

7. My practitioner will respond to communications and routine messages within 48 hours on

business days or on the next business day following weekends, holidays, or vacations.

8. I

t is my responsibility to maintain privacy on the client end of communication. Insurance

companies, those authorized by the client, and those permitted by law may also hav

cess to records or communications.

9. I

will take the following precautions to ensure that my communications are directed only

to my behavioral health practitioner or other designated individuals: Double check email

addresses; double check phone numbers; double check to whom email is sent (reply vs

reply all).

10. M

y communication with my behavioral health practitioner will be stored in the following

manner: In compliance with HIPAA regulations in secured file cabinets and/or secured

electronic medical record files.

11. T

he laws and professional standards that apply to in-person behavioral services als

appl

y to telehealth services. This document does not replace other agreements,

contracts, or documentation of informed consent.

_______________________________________

Client Printed Name

_______________________________________ ____________

Signature of Client or Legal Guardian Date

mega J. Galliano, MFT, LADC, LP

Practitioner Printed Name

_______________________________________

_____________

Signature of Practitioner Date

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signature

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Addendum A

Client Name: ________________________________

I, the undersigned, a citizen of ______________________ or my designee(s) _____________

on my behalf, agree to participate in technology-based consultation and other health-care

related information exchanges with Omega J. Galliano, a behavioral healthcare practitioner

(“practitioner”). This means that I authorize information related to my medical and behavioral

health to be electronically transmitted in the form of images and data through an interactive

video connection to and from the above-named practitioner, other persons involved in my health

care, and the staff operating the consultation equipment. It may also mean that my private

health information may be transmitted from my practitioner’s mobile device to my own or from

my device to that of my practitioner via an ‘application’ (abbreviated as “app”).

You understand that a variety of alternative methods of mental health care may be available to

you, and that you may choose one or more of these at any time. Your mental health care

provider has explained the alternative to your satisfaction.

I represent that I am using my own equipment to communicate and not equipment owned by

another, and specifically not using my employer’s computer or network. I am aware that any

information I enter into an employer’s computer can be considered by the courts to belong to my

employer and my privacy may thus be compromised.

I understand that I will be informed of the identities of all parties present during the consultation

or who have access to my personal health information and of the purpose for such individuals to

have such access.

My health care practitioner has explained how the telehealth consultation(s) is performed and

how it will be used for my treatment. My health care practitioner has also explained how the

consultation(s) will differ from in-person services, including but not limited to, emotional

reactions that may be generated by the technology.

You understand that it is your duty to inform your physician of electronic interactions regarding

your care that you may have with other health care providers.

In brief, I understand that my practitioner will not be physically in my presence. Instead, we will

see and hear each other electronically, or that other information such as information I enter into

an “app” will be transmitted electronically to and from my practitioner and I. Regardless of the

sophistication of today’s technology, some information my practitioner would ordinarily get in in-

person consultation may not be available in teleconsultation. I understand that such missing

information could in some situations make it more difficult for my practitioner to understand my

problems and to help me get better. My practitioner will be unable to physically touch me or to

render any emergency assistance if I experience a crisis.

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I understand that telehealth consultation(s) are a new form of treatment, in an area not yet fully

validated by research, and that they have potential risks, possibly including some that are not

yet recognized. Among the risks that are presently recognized is the possibility that the

technology will fail before or during the consultation, that the transmitted information in any form

will be unclear or inadequate for proper use in the consultation(s), and that the information will

be intercepted by an unauthorized person or persons.

In rare instances, security protocols could fail, causing a breach of privacy of personal health

information. I understand that a physical examination may be performed by individuals at my

location at the request of the consulting practitioner.

I authorize the release of any information pertaining to me determined by my practitioner, my

other health care practitioners or by my insurance carrier to be relevant to the consultation(s) or

processing of insurance claims, including but limited to my name, Social Security number, birth

date, diagnosis, treatment plan and other clinical or medical record information.

I understand that at any time, the consultation(s) can be discontinued either by me or by my

designee or by my health care practitioners. I further understand that I do not have to answer

any question I feel is inappropriate or whose answer I do not wish persons present to hear; that

any refusal to participate in the consultation(s) or use of technology will not affect my continued

treatment and that no action will be taken against me. I acknowledge, however, that diagnosis

depends on information, and treatment depends on diagnosis, so if I withhold information, I

assume the risk that a diagnosis might not be made or might be made incorrectly. Were that to

happen, my telehealth-based treatment might be less successful than it otherwise would be, or

it could fail entirely.

I also understand that, under the law< and regardless of what form of communication I use in

working with my practitioner, my practitioner may be required to report to the authorities

information suggesting that I have engaged in behaviors that endanger others.

The alternatives to the consultation(s) have been explained to me, including their risks and

benefits, as well as the risks and benefits of doing without treatment. I understand that I can still

pursue in-person consultations. I understand that telehealth consultation(s) does not

necessarily eliminate my need to see a specialist in person, and I have received no guarantee

as to the telehealth consultation’s effectiveness.

I understand that my telehealth consultation(s) may be recorded and stored electronically as

part of my medical records. The practitioner will inform me if this is to occur and the reasons for

this being necessary. I understand that consultations, test results, and disclosures will be held

in confidence subject to state and/or federal law. I understand that I am ordinarily guaranteed

access to my medical records and that copies of records of consultation(s) are available to me

on my written request. I also understand, however, that if my practitioner, in the exercise of

professional judgment, concludes that providing my records to me could threaten the safety of a

human being, myself or another person, he/she may rightfully decline to provide them. If such a

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request is made and honored, I understand that I retain sole responsibility for the confidentiality

of the records released to me and that I may have to pay a reasonable fee to get a copy.

Additionally, I understand that my records may be used for telehealth program evaluation,

education, and research and that I will not be personally identified if such a use occurs. I

hereby authorize these disclosures to take place without prior written consent.

I understand that I am not entitled to royalties or to other forms of compensation for participation

in any telehealth consultation(s) or information exchange.

I have received a copy of my practitioner’s contact information, including his/her name,

telephone number, business address, mailing address, and email address (if applicable). I have

also been provided with a list of local support services in case of an emergency. I am aware

that my practitioner may contact the proper authorities and/or my designated local contact

person in case of an emergency.

I acknowledge, however, that I am facing or if I think I may be facing an emergency situation

that could result in harm to me or to another person; I am not to seek a telehealth consultation.

Instead I agree to seek care immediately through my own local health care practitioner or at the

nearest hospital emergency department or by calling 911.

These are the names and telephone numbers of my local emergency contacts (including local

physician; crisis hotline; trusted family, friend or adviser).

____________________________________________________________________________