Medical Services/Consent to Participate in Telehealth Services Template (08/31/20) Page 1 of 1 973c
, have been asked to receive behavioral health services through the
telehealth system. I understand the use of the video conferencing equipment is a method of health care delivery in which services are
delivered to an individual by a provider at a site other than where the individual is located. I understand that I will be receiving health care
services through the telehealth system. I understand that, at this time, there are no known risks involved with receiving my care in this
I understand that I will communicate through the telehealth system with a health care provider located at another location. I understand
there are no additional charges or fees for clinical services I will receive through the use of the telehealth system. I understand that my
participation in telehealth is voluntary and I may refuse to participate or decide to stop participation at any time. I have been informed of
the potential consequences of my refusal to participate or stop participation in telehealth services.
I understand that my privacy and confidentiality will be protected. I also understand communication through the telehealth system occurs
over secure telecommunications lines dedicated for this purpose. I understand that the likelihood of a videoconference being intercepted
by an outsider is similar to the potential interception of a phone call. I understand no video or audio recording of the service(s) will be
made without my consent. When I am receiving services through the telehealth system, I understand I will be notified as to who is in the
room at the remote site.
I understand that the health care providers at both my location (if applicable) and the remote video site may have access to any relevant
medical information about me including any psychiatric and/or psychological information, alcohol and/or drug abuse, and mental health
Additionally, as part of Compass Health telehealth services, Compass Health has the ability to send information via e-mail and text
messaging for non-urgent matters through a secured mechanism. You may receive e-mail or text messages from your clinician
for items such as: a request that you call your clinician, or documents related to your treatment such as a consent to treatment
or client rights. Please only respond to Compass Health emails via the ‘reply’ feature within the secure email or via the secure
texting App for text messages. Email and texting should not be used in emergencies or for any urgent communication.
Compass Health cannot and does not guarantee the privacy or security of any messages being sent by e-mail or text
messaging. Routine reminder phone calls and/or text messages, when chosen by you, are not covered by this consent. It is
your responsibility to inform Compass Health of your current email address and telephone number and of any changes to your contact
I have read this document and I hereby consent to participate in behavioral health services through the telehealth system including
electronic correspondence under the terms described above. I understand this document will become a part of my medical record.
Client Signature
Witness Signature
If the client is age 12 and below, or has been determined to be incompetent to give informed consent please complete below:
Parent, Legal Guardian, or Authorized by the Court
Relationship to Client
Witness Signature
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