Counseling Connections 2016
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