The purpose of this form is to obtain your consent to participate in a telemedicine consultation in connection with one or more of the following procedures and/or services:
• Addiction Recovery Treatment Services • Medical Medication Management Services
• Psychosocial Assessment • Care Coordination
• Diagnostic Assessment • Family or Group Counseling/Training
• Individual Therapy • Nursing Services
• Peer Support • Psychiatric Treatment
• Service Plan Development •
Informed Consent to Telehealth Services
Telehealth is a delivery of health services using interactive technologies (e.g., phone or video sessions) between a practitioner and a client who are not in the same physical location. All practice policies remain the same, including that you agree to be on time for your session, and you follow the practice’s cancellation policy if you are unable to attend your appointment.
Nature of Telemedicine Visit or Consult:
During the telemedicine or telehealth consultation:
a. Details of your medical history, examinations, x-rays/imaging results, and test results will be discussed with you and/or other professionals using interactive video, audio, and telecommunication technology.
b. A physical examination of you may take place.
c. A non-medical technician may be present in the telemedicine service area to aid in the video transmission.
d. Doxy.me does not record/store data from your telehealth session, but your Provider may take Video, audio, and/or photo recordings. These would only be taken of you during the procedure(s) or service(s) if it is relevant/necessary for your care.
Medical Information & Records:
All existing laws about your access to medical information and copies of your medical records apply to this telemedicine consultation. Please note, not all telecommunications are recorded and stored. Additionally, dissemination of any patient-identifiable images or information for this telemedicine interaction to researchers or other entities shall not occur without your consent.
Privacy, Confidentiality, & Integrity of Services Provided:
You will not be in the same room or even location as your healthcare provider. Reasonable and proper efforts are made to prevent risks to your privacy and confidentiality during the telehealth appointment and all existing confidentiality protections under federal and state law applicable to information that might be disclosed during telehealth visits.
You must be in a confidential location during your telehealth visit (i.e., alone, in a secure, non-public, stationary location). If you are not in a private and secure location, you must tell your provider BEFORE the start of the visit, and your appointment may be rescheduled. ReVIDA Recovery Centers’ healthcare providers will not participate in a telehealth visit while you are at work, in the presence of people who are not part of your care team, or in a vehicle as driver or passenger, or a public location such as a retail store.
You must present appropriately for your telehealth appointment. You are expected to be fully clothed and sitting in a well-lit room. Examples of presenting inappropriately would be situations where you are not fully clothed, laying in a bed, or in a dark room.
Rights & Limitations:
You may withhold or withdraw consent to telemedicine at any time without affecting your right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled. The level of care provided by your healthcare provider via telehealth is to be the same level of care that is available to you through an in-person medical or counseling visit. However, if your provider believes you would be better served by face-to-face services or another form of care, you will be referred to a physical office for your appointment. You have the right to receive face-to-face medical or behavioral health services at any time by traveling to my local ReVIDA Recovery Centers location.
Location and Disputes:
The laws of the state in which you are located will apply to your telehealth services. Your healthcare provider must be licensed to practice in the state in you are located while receiving services. You must report your location accurately during each visit with ReVIDA Recovery Centers staff. If you are not located in the state in which your physician or counselor is licensed, your appointment may need to be rescheduled. You agree that any dispute arriving from the telemedicine consultation will be resolved in the state in which you live, and the laws of that state will apply to all disputes.
Risks, Consequences, & Benefits:
Potential benefits of telehealth (which are not guaranteed or assured) include: (i) access to medical care if I am unable to travel to my provider’s office; (ii) more efficient medical evaluation and management; and (iii) during the COVID-19 pandemic, reduced exposure to patients, medical staff, and other individuals at a physical location. Potential risks of telehealth include: (i) limited or no availability of diagnostic laboratory; (ii) my provider’s inability to conduct a hands-on physical examination of me and my condition; and (iii) delays in evaluation and treatment due to technical difficulties or interruptions, distortion of diagnostic images or specimens resulting from electronic transmission issues, unauthorized access to my information, or loss of information due to technical failures. By checking this box, you agree that you will not hold ReVIDA Recovery Centers responsible for lost information due to technological failures.
You agree that you have been advised that your healthcare provider’s advice, recommendations, and/or decisions may be based on factors not within his/her control, including incomplete or inaccurate data provided by me. You understand that your provider relies on information provided by you before and during your telehealth encounter and that you must provide information about your medical history, condition(s), and current or previous medical care that is complete and correct to the best of your ability.
By checking this box, you consent to, understand, and agree that you have been advised of the potential risks, consequences, and benefits of telemedicine and agree to the following:
1. I understand that a telehealth session has potential benefits including easier access to care, the convenience of meeting from a location and time of your choosing, and ability to limit one’s physical contact with others during COVID-19.
2. I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties.
3. I understand I need to have access to the appropriate technology to participate in the service provided. This includes being on a secure internet connection, rather than public or free Wi-Fi. For video sessions, being in a room where there is good lighting, keeping the video steady by either placing your computer on a hard surface or leaning your phone against something sturdy, and keeping your camera on throughout the entirety of the
session.
4. I need to be in a location free of disruptions, where I am alone and can speak freely, and where others will not see the screen, or hear the conversations of the group or individual session. This may include using headphones if necessary.
5. I have access to my provider so I can ask any questions I have about potential risks, benefits, and any practical alternatives to telehealth. Your health care practitioner has discussed with you the information provided in this document. You have had the opportunity to ask questions about the information presented on this form and the telemedicine consultation.
6. I understand that should the provider determine, due to certain circumstances, that telehealth is no longer appropriate, we can resume in-person sessions at the next available appointment. At that time, there may be separate informed consent regarding returning to in-person services.
7. I understand I can decline telehealth services at any time without jeopardizing access to future care.
8. I understand the provider uses a confidential, HIPAA compliant video platform that safeguards data and provides a secure platform. However, there is always the potential risk to client confidentiality when the internet is involved, and this is heightened in participation in a group format.
9. Group Participation-In addition to the telehealth requirements listed above, I agree to follow the rules specific to maintaining confidentiality in a group session setting.
a. To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment. I will not record or photograph any part of the group or the group members or allow anyone into my room while the group is in session.
b. I understand that I may learn the full names of group members due to their name being listed on the video. I agree not to seek out any information about group members (e.g., using a search engine or social media), nor contact them outside of group if this is against the specific group agreements.
c. If I choose not to show my full name, I will ask the group leader how to change my display name, if I do not know how to do it.
d. I can inform my provider I would prefer to wait until the next in-person appointment, though this may impact your membership in the group.
e. If I am at a different location, other than my home and in a private area, then I will inform the group leader in advance of my new location.
f. If you are temporarily located out of state, this may impact your ability to attend the session due to licensure rules.
By clicking “I agree to Terms of Use” on the Doxy.me Telehealth portal, you consent to, understand, and agree that you have been advised of the potential risks, consequences, and benefits of telemedicine and agree to the following:
A. All my questions have been answered, and I understand the written information provided in this document.
B. I have reviewed, understood, and accept the risks and benefits of telehealth services as described and wish to receive such services, and
C. I agree with the remaining terms of this Consent, including the terms of the Doxy.me Privacy Notice, as described upon log-in to the platform.
