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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.
• Community & Family Resources/The Richmond Center 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/TRC has policies and practices in place to safeguard the privacy of all client information whether written or in electronic form. CFR/TRC 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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