Wake Forest Baptist Health
This authorization and consent to participate in telehealth is not a substitute for the general Healthcare Consent form and HIPAA Notice of Privacy Practices Acknowledgment, which should be completed separately at the initiation of services with adult patients and/or persons authorized to consent on behalf of the patient.
Definition and Details:
Telehealth refers to medical/clinical services that are provided remotely using videoconferencing or telephone. To participate in videoconferencing, there is necessary technology, hardware, software, internet access, and competency with technology that is required. You as the patient or legal caregiver together with the provider will determine the best form of telehealth to use during your sessions based on access, your preference, and clinical indications. If you will be using videoconferencing sessions, you will receive the appropriate instructions in advance.
You or the minor patient are entitled to the same rights and have the same responsibilities as with in-person sessions. Providers will maintain the same level of ethical conduct and protection of privacy, including the maintenance of records, as with in-person sessions.
Benefits and Risks:
Benefits of telehealth include: a) you and your provider do not have to be in the same physical location, promoting more consistent visits and easier access to care, b) saving time and money involved with traveling to and from appointments, c) telehealth can be as clinically effective as in-person services, d) allowing for clinical visits to continue in the context of social distancing recommendations related to infectious outbreaks.
Telehealth is a billable service, and insurance or you (if no insurance) will be billed accordingly. Fees for telehealth may be comparable to in-person session fees. Most insurance companies have wider coverage of telehealth during infectious outbreaks. Check with your insurance company and/or behavioral health plan or the billing department at WFBH for more information. There may be additional costs incurred during telehealth visits due to data usage or technology, and you or legal caretaker(s) are responsible for such costs.
I have been advised of all the potential risks, consequences, and benefits of telehealth. My provider has discussed with me the information provided above. I have had an opportunity to ask questions about this information, and all of my questions have been answered. I understand the information provided herein.