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Informed Consent for Telehealth Treatment (Web)

Community & Family Resources
Phone 515-576-7261
Fax 515-955-7628
 Client Information
  First Name:  * Last Name:  *  
           
  Date of Birth:  * Birth Sex: 
* 
         
  Address: City:  
  State: Zip Code :  
  Phone No:  
Date
Medicaid #
Medicare #
Telehealth/Telemedicine:
Telehealth/telemedicine involves the use of interactive, secure electronic communications that enables a health care provider to provide services to a client at a different location via live two-way audio/video communication. Services provided via telehealth may include appointments for psychiatric care, therapy, and counseling.

I understand that:
• The appropriateness of telehealth services will be determined in collaboration with my assigned provider, and we will agree on the nature, volume, and frequency which supports effective services.
• I will be oriented to the equipment used for telehealth services and provided the opportunity to request reasonable accommodations.
• Electronic communication is not to be used for any emergency or crisis communications and I will utilize the established emergency phone contact procedures if needed.
• CFR reserves the right to cease the use of telehealth services at any time.
• I retain the right to refuse telehealth services at any time without affecting my right to future care or treatment. If I decline telehealth services, other alternative options are available to me, including in person services, which may involve travel.
• All existing confidentiality laws shall apply to my telehealth services.
• I shall have access to all medical information resulting from the telehealth services, as provided by law.
• I will be informed whether the telehealth service will be or will not be recorded.
• I will be informed of all people who will be present at all sites during my telehealth service and I retain the right to exclude anyone from either the originating site (where I am located) or distant site (where the provider is located).
• CFR has policies and practices in place to safeguard the privacy of all client information whether written or in electronic form. CFR agrees to use electronic systems that incorporate network and software security protocols to protect confidentiality and protect against intentional or unintentional corruption or access. There is a risk that security protocols could fail or be breached, causing the privacy of my personal medical information to potentially be compromised.
• I am responsible to safeguard the privacy of my telehealth service(s) from access by others in the environment that I am in at the time of the telehealth service.
• I am responsible for any copayments or coinsurances that apply to my telehealth service(s).
* Is the client willing and able to sign in agreement?
Yes  
No  
If not, explain:
* Signature of Client:
Signer Type:  
  Client (Please click "Sign with Touch" and oversee / assist the Client in signing.)
  Other (Please enter the Name of the signer below and indicate relationship with the Client then click "Sign with Touch" and oversee / assist the signing. For example: Jane Doe, mother)
   
Name:
 
Sign with Touch
Signature of Legally Authorized Representative:
Signer Type:  
  Client (Please click "Sign with Touch" and oversee / assist the Client in signing.)
  Other (Please enter the Name of the signer below and indicate relationship with the Client then click "Sign with Touch" and oversee / assist the signing. For example: Jane Doe, mother)
   
Name:
 
Sign with Touch
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