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:

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.

Risks:

1. Confidentiality. The provider will ensure that your sessions are private and confidential to the extent possible. However, there may be challenges with confidentiality using telehealth including: the potential for others to overhear and/or oversee sessions on your end, as well as technology-related issues (e.g., others accessing your private conversations or stored information without your knowledge). It is recommended that you are in a private and quiet place during your session. When possible, use a secure internet connection rather than public/free Wi-Fi to protect your privacy. The sessions will not be recorded without your permission.
2. Interruptions during sessions. (a) While privacy is a priority during telehealth, unexpected interruptions may be more likely to occur outside of the provider’s office. (b) Technology may unexpectedly stop working during a session. If the connection is lost during a session, your provider will try to reconnect with you immediately and then every 5 min for 15 minutes or until your session time has expired, whichever comes first. If your provider is unable to reconnect with you during the session time and the situation is not urgent, your provider or proxy will reach out to reschedule or schedule a follow-up appointment. If you are disconnected from your provider and your provider is unable to immediately reach you during an urgent or emergency situation, your provider will attempt to reach your emergency contact person and might call 911 or the Mobile Crisis Unit (for behavioral health issues) to respond, if necessary. In the event that your provider is unable to reach you and you are still in need of emergency assistance, you should call 911 or the mobile crisis unit (for behavioral health issues), or have someone take you to an emergency department.
3. Effectiveness. Most research shows that telehealth is effective. However, certain aspects of telehealth may be different and less ideal compared with in-person sessions. For example, it may be more difficult for the provider to pick up on nonverbal communication during telehealth compared with in-person sessions.
   Rev. 3/25/20
4. Crisis Management. It can be more difficult and riskier to manage a crisis situation via telehealth versus in-person sessions. However, during periods of infectious outbreak with social distancing recommendations, telehealth services may be available to you if you are experiencing a more critical situation. To ensure your safety, the following measures will be taken:
   1. At the beginning of the session, you will be required to inform the provider of your location address in case of emergency.
   2. You will be required to inform your provider of the name and phone number(s) for at least one emergency contact person, who may be contacted in case of emergency. In the case of a minor, this is usually the legal caregiver.
   3. If you are at high medical or psychiatric risk as determined by your provider, then the provider might require that there is a responsible adult located close by during your sessions.
   4. If you are at high medical or psychiatric risk, the provider will work with you to develop an emergency response plan to address potential crisis situations that might arise during your sessions.
   5. If there is an active crisis during your visit, or if your provider is concerned about serious risk of harm to you or others, the provider may call the emergency contact person, 911 or the Mobile Crisis Unit (for behavioral health issues). For minor patients, a parent or legal caregiver might be instructed to bring the patient to an emergency department.

Financial:
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.

Attestation
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.