Telemedicine Consent Form
California law has long recognized telemedicine as a form of delivery of health care and behavioral health services. Telemedicine is a method to deliver health care services using information and communication technologies to facilitate the diagnosis, consultation, treatment, and care management while the patient and provider are in two different locations. This form of service is usually live video conferencing through a personal computer, tablet, or cell phone. At Neuro Wellness Spa, your provider may recommend telemedicine as an option for your continued care.
I understand that I have the following rights with respect to telemedicine:
1. I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment or risking the loss or withdrawal of any benefits to which I would otherwise be entitled.
2. The laws that protect the confidentiality of my medical information also apply to telemedicine. As such, I understand that the information disclosed by me during my treatment is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to, reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding.
3. I understand that there are risks and consequences from telemedicine, including, but not limited to, the possibility, despite reasonable efforts on the part of my psychiatrist, that: the transmission of my medical information could be disrupted or distorted by technical failures; the transmission of my medical information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons.
4. I understand that in the event of a technical failure, my psychiatrist will attempt to call me at the phone number provided in my chart. If for whatever reason my telemedicine appointment cannot be completed at that time, my appointment will be rescheduled within the week.
5. I understand that it is my responsibility to maintain my telemedicine communication platform at my site.
6. I understand that my psychiatrist must recommend telemedicine as an appropriate level of care after an initial in-person consultation.
7. I understand that at any point during my care, my psychiatrist may recommend an additional psychiatric service (in person visit, referral to an inpatient/ outpatient provider in my area).
8. In between appointments, I can communicate with the physician’s assistant. I will receive the contact information during my first in-person visit.
9. I understand that Neuro Wellness Spa may contact me via nonsecure email or phone/text communication regarding my health or treatment. Risks of this include interception during transmission as well as upon receipt of the message, including the reading, copying, or forwarding by anyone who might have access to the message platform, intentionally or not. I may revoke this at any time by contacting my clinician’s assistant.
10. I understand that my psychiatrist will maintain electronic documentation of my treatment. This documentation will be written.
Video will never be recorded during a telemedicine appointment.
11. I understand I should:
Be ready and prepared five minutes before my scheduled appointment time.
Be in an area that is safe, private, and appropriate for a video session.
Not have anyone in the room with me unless first discussed with my mental health provider.
Be prepared to devote my full attention to my mental health provider.
Refrain from conducting other activities, such as working, eating, or driving, while in session.
Have a reliable internet connection in the location my session will take place.
If I am not in a safe, private location, free from distractions, and/or if I am more than ten minutes late, I understand my provider will reschedule my appointment and I will be charged a $100 cancellation fee.
12. I understand that If I have an emergency, feel suicidal or homicidal I will follow the plan indicated below:
Call 911 Call or visit Del Amo Behavioral Health System 23700 Camino Del Sol Torrance, CA 90505 (310) 530-1151 Go to the nearest hospital emergency room Torrance Memorial 3300 Lomita Blvd Torrance, CA 90505 (310) 325-9110 Providence Little Company of Mary 4101 Torrance Blvd Torrance, CA 90503 (310) 303-5600 Harbor-UCLA Medical Center 1000 w Carson St Torrance, CA 90509 (310) 222-2345 Call the Suicide Prevention Lifeline 1-800-273-8255 I understand and agree to the above terms. I have discussed telemedicine with my psychiatrist, and all my questions have been answered to my satisfaction.