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WAUKESHA COUNTY DEPARTMENT OF HEALTH AND HUMAN SERVICES (Waukesha County Government)

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WAUKESHA COUNTY DEPARTMENT OF HEALTH AND HUMAN SERVICES
CLINICAL SERVICES INFORMED
CONSENT FOR TELEHEALTH SERVICES
CLI-0140; 04/20, Rev. 05/20, 06/20 Page 1
Patient Name:
MRN:
Date of Birth:
The purpose of this document is to obtain consent for Telehealth Services with Waukesha
County Department of Health and Human Services (WCDHHS). In order to maintain care under
certain circumstances, including during periods of any closure (mandatory or voluntary) for any
reason, we may offer to conduct individual and/or group psychotherapy, psychotherapy with
medication management, and assessments via telehealth service. Telehealth service is the
delivery of healthcare services when the provider and consumer are not in the same physical
location/site through the use of various technologies. This could include video sessions via
telehealth software on a computer, tablet or other approved electronic devices.
Definition of Telehealth
Variously dubbed telemedicine, tele therapy, distance therapy, e-therapy, internet therapy, or
online therapy, “telehealth” is defined as the use of electronic transmission to provide interactive
real-time mental health services remotely, including consultation, assessment, medication
management, diagnosis, treatment planning, counseling, psychotherapy, coaching, guidance,
psycho-education, education and transfer of medical information with an experienced provider.
Due to the rapidly changing circumstances, the approved platform (i.e.: telephone call, email,
texting) of the delivery of these services are subject to change. In the event the above-
mentioned delivery platforms are approved methods of communications, this consent
will serve as authorization to deliver services in that manner.
Agreements
Telehealth is governed by all the same ethics and laws that cover in-person, in-office services.
Consequently, all other policies, consents and agreements signed with your provider apply to
telehealth services as well. This document is an addendum to all in-office services agreements,
and does not substitute or replace any such agreements.
Advantages and Disadvantages
The main advantage of telehealth is that it provides flexibility for continuity of care when in-
person sessions cannot be conducted. Telehealth by videoconference allows for both verbal
and non-verbal communication in a way that is similar but not identical to in-person
communication.
Telehealth is not a universal substitute, nor the same as in-person psychotherapy services.
Some report that telehealth services do not provide the same level of ease, comfort and
connection, and may not seem as “complete” when discussing personal and private matters.
Body language is not as fully visible. Misunderstandings may occur more easily. These
differences may impact the quality of the professional therapeutic relationship. Just as with in-
person psychotherapy, the effectiveness of telehealth services cannot be guaranteed. Discuss
any concerns as they arise.
Prerequisites
Telehealth requires some reasonable comfort with technology. Telehealth is best for
augmenting in-person services when a client is unable to come to the office location due to
WAUKESHA COUNTY DEPARTMENT OF HEALTH AND HUMAN SERVICES
CLINICAL SERVICES INFORMED
CONSENT FOR TELEHEALTH SERVICES
CLI-0140; 04/20, Rev. 05/20, 06/20 Page 2
Patient Name:
MRN:
Date of Birth:
temporary limitations, such as medical conditions limiting physical mobility, distance due to
travel, and scheduling conflicts, etc. To provide optimal care, ideally in-person sessions are
recommended.
Under certain extreme circumstances when telehealth should not be provided due to the nature
of therapeutic services needed, your provider may recommend: coming into the office, waiting
until you can come into the office, or referring you to a provider who can provide such services
in-person. With the COVID-19 pandemic, receiving in-person therapy services from anyone may
become very challenging; telehealth provides a great alternative to in-person services, when
possible.
Emergencies
Telehealth is not recommended for any mental health emergency. If your provider believes you
would be better served with in-person service and your provider is unable to provide that, you
will be referred to a provider in your area that can provide such services.
Just as with in-person services, if an emergency should occur during a telehealth session, your
provider will consider taking any steps necessary to ensure your safety and that of others.
Scheduling
Telehealth sessions will be scheduled ahead of time. These appointments reserve time
specifically for you. Just as with in-person appointments, you are responsible for keeping and
paying for all telehealth appointments.
We will start and end on time. In all telehealth sessions, the provider will initiate the telehealth
session, unless other arrangements are made in advance. A window of 15 minutes will remain
open after the start time of your session. Just as with an in-person session, if your provider
doesn't hear from you or can’t get through to you, the provider will attempt to contact you via
phone.
Cancellations and missed appointments are handled in the same way as in-person
cancellations are handled in other forms. The provider cannot be responsible for the client’s
ability to participate in sessions, including technological difficulties or disruptions.
Confidentiality
The same laws protecting the confidentiality of your medical information in the office apply to
telehealth sessions, including law that protects substance use records, 42 CFR Part 2. This also
includes mandatory reporting and permitted exceptions under HIPAA, such as child, elder and
dependent adult abuse reporting, risks to the client’s wellbeing, threats of violence to an
identifiable victim and when clients enter their own emotional or mental factors into a legal
proceeding.
The client and provider both agree to keep the same privacy safeguards used during in-person
sessions. Ensure that your environment is free from unexpected or unauthorized intrusions or
disruptions to our communication. You are asked to preserve privacy and limit the risk of being
overheard by a third party by conducting the session in a private room with closed doors, with
WAUKESHA COUNTY DEPARTMENT OF HEALTH AND HUMAN SERVICES
CLINICAL SERVICES INFORMED
CONSENT FOR TELEHEALTH SERVICES
CLI-0140; 04/20, Rev. 05/20, 06/20 Page 3
Patient Name:
MRN:
Date of Birth:
reasonable sound barriers, and no one else present or observing, unless session is occurring
on-site and telehealth staff need to be present. Earphones may be very helpful to help you
preserve privacy as well. The client and provider both agree to not record the telehealth
sessions without prior written consent.
Consent
You have the right to opt in or opt out of telehealth communication at any time, without
affecting your right to future care or treatment, except during the COVID 19 pandemic
when in-person sessions will not be available for a period of time. Please discuss this
thoroughly with your provider.
Your signature below indicates that you understand that you are responsible for learning
to handle the specific medium used, prior to your telehealth sessions, and to engage in
any necessary rehearsals to ensure effectiveness.
Security
No electronic transmission system is considered completely safe from intrusion. While a variety
of software programs are available for video conferencing, such as Skype, Facetime, or
GoToMeeting, most are not encrypted, or compliant with Federal law to protect the privacy of
your health communication.
Interception of communication by third parties remains technically possible. You are responsible
for information security on your own computer, laptop, tablet, or smartphone.
Due to the complexities of electronic media and the internet, the risks of telehealth include the
potential for the release of private information, including audio, written materials and images
which may be disrupted, distorted, interrupted or intercepted by unauthorized persons, despite
your provider’s reasonable efforts. Consequently, your provider cannot fully guarantee the
security of telehealth sessions.
Video Conferencing
At the time of the telehealth appointment, if the originating site is the client’s home, it is the
client’s responsibility to have their electronic device on, video conferencing software launched,
and be ready to start the session at the time of the scheduled telehealth appointment. This
requires setting up, a few minutes prior to each start time. The client is responsible for his/her
own hardware and software, audio and video peripherals, and connectivity and bandwidth
considerations.
For telehealth services provided on-site, it is the responsibility of the telehealth staff to ensure
electronic device is on, video conferencing software is launched, and ready to start the session
at the time of the scheduled appointment.
If a video telehealth session is disrupted after reasonable attempts, we may have to reschedule
the session or switch to a phone call to discuss next steps.
WAUKESHA COUNTY DEPARTMENT OF HEALTH AND HUMAN SERVICES
CLINICAL SERVICES INFORMED
CONSENT FOR TELEHEALTH SERVICES
CLI-0140; 04/20, Rev. 05/20, 06/20 Page 4
Patient Name:
MRN:
Date of Birth:
Payment & Insurance
Telehealth services are professional services and are subject to the same rate as in-person
services.
Clients that may be relying on insurance or any other third-party coverage for service
reimbursement are advised to contact the insurance company to determine if telehealth is
covered benefit by the policy. Even when health insurance covers in-person services, health
insurance may limit or deny coverage of telehealth services. If your insurance does not cover
telehealth services, you will personally be responsible for payment.
Information on Telehealth Sessions
• Client will need to use a webcam or smartphone during the session unless this is a
service being provided on-site.
• It is important to be in a quiet, private space, in your own residence, that is free of
distractions (including cell phone or other devices) during the session.
• It is important to use a secure internet connection rather than public/free Wi-Fi.
• It is important to be on time. If you need to cancel or change your telehealth-
appointment, you must notify your provider by phone, in advance of your scheduled
time.
• We are in need of a valid phone number to reach you in the event of any technical
difficulties (to restart the session, to reschedule the session, or in the event of technical
difficulties, etc.).
• If you are not an adult, we need the permission of your parent or legal guardian (and
their contact information) for you to participate in telehealth sessions.
• You should confirm with your insurance company that the video sessions will be
reimbursed; if they are not reimbursed, you are responsible for full payment.
• Your provider may determine that due to certain circumstances, telehealth is no longer
appropriate and that we should resume our sessions in-person.
Since this may be different than the type of sessions with which you are familiar, it is
important that you understand, acknowledge, and agree to the following statements:
• You understand that you have agreed to engage in a telehealth encounter for yourself
that will contain personal identifying information as well as protected health information.
• You understand that the provider will be at a different location from you.
• You understand that you have the right to withhold or withdraw your consent to the use
of telehealth services at any time in the course of your care, without affecting your right
to future care or treatment.
• You have been informed of and accept the potential risks associated with telehealth,
such as failure of security protocols that may cause a breach of privacy of personal
and/or medical information.
• You 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 you will be disclosed to other entities without your consent or
as may be allowed by law.
WAUKESHA COUNTY DEPARTMENT OF HEALTH AND HUMAN SERVICES
CLINICAL SERVICES INFORMED
CONSENT FOR TELEHEALTH SERVICES
CLI-0140; 04/20, Rev. 05/20, 06/20 Page 5
Patient Name:
MRN:
Date of Birth:
• Yo
u have been given the opportunity to ask your provider at WCDHHS questions
relative to your Telehealth encounter, security practices, technical specifications, and
other related risks.
By signing this form, you certify:
• That you have read or had read and/or had this form explained to you;
• That you fully understand its contents including the risks and benefits of teleheal
th
se
rvices;
and
• That you have been given ample opportunity to ask questions and that any questions
have been answered to your satisfaction.
Client/Guardian* Signature
Date
Client/Guardian* Name (Please Print)
Client Email Address
* If signed by a person other than the client, complete the following:
Client is:
Minor
Unable to sign due to disability
Legal Authority:
Parent of Minor
Legal Guardian
Power of Attorney (POA)
Other:
* If you check any of the above boxes, you must have proof of legal authority (i.e. Guardianship Papers, Power of Attorney documents) *
Physical Address From Which I Will Be Communicating Privately For Telehealth Sessions:
Street Address
City/State
Zip Code
Person Obtaining Consent Signature
Date
Person Obtaining Consent Name (Please Print)
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WAUKESHA COUNTY DEPARTMENT OF HEALTH AND HUMAN SERVICES (Waukesha County Government)

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Completed 15 May 2021

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