WP E-Signature by Approve Me - Sign Documents Using WordPress -

Consent to Telehealth

Informed Consent Checklist for Telehealth services (sessions over the internet/video sessions) :

Confidentiality still applies for telepsychology services, and nobody will record the session without the permission from the others person(s).
There are potential benefits and risks of video-conferencing (e.g. limits to patient confidentiality) that differ from in-person sessions.

You need to use a webcam or smartphone during the session.
It is important to be in a quiet, private space that is free of distractions (including cell phone or other devices) during the session.
It is important to use a secure internet connection rather than public/free Wi-Fi.
It is important to be on time. If you need to cancel or change your tele-appointment, you must notify the clinician in advance by phone or email.
If your session has technical difficulties and you need to restart the session or to reschedule, your clinician will contact you directly using the phone number on file or one you provided during the session.

We agree to use the video-conferencing platform selected for our virtual sessions, and the clinician will explain how to use it as well as the log in and payment procedure
We need a safety plan that includes at least one emergency contact and the closest emergency room to your location, in the event of a crisis situation.
If you are not an adult, we need the permission of your parent or legal guardian (and their contact information) for you to participate in telehealth sessions.
You should confirm with your insurance company that the video sessions will be reimbursed; if they are not reimbursed, you are responsible for full payment (many commercial and Medicare plans currently allow for these sessions).
As your Clinician, I may determine that due to certain circumstances, telehealth is no longer appropriate and that we should resume our session’s in-person.

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

Draw your signature with your mouse, tablet or smartphone Clear

I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

Timestamp

Audit

May 21, 2020 1:35 pm EDT

Consent to Telehealth Uploaded by Lisa Feraco - [email protected] IP 50.73.169.97

May 28, 2020 11:51 am EDT

Document owner [email protected] has handed over this document to [email protected] 2020-05-28 11:51:53 - 162.144.177.109