Informed consent for telehealth services

Draft for review. Patients sign a copy of this consent in the intake packet before their first visit.

What telehealth is

Telehealth means receiving psychiatric evaluation and medication management through live, interactive audio and video technology rather than in person. Your provider is a psychiatric mental health nurse practitioner licensed in the state where you are located at the time of the visit.

Benefits and possible risks

Telehealth gives you access to care without travel and often with shorter waits. Possible risks include technical interruptions, and the fact that some assessments that require physical examination cannot be completed by video. If your provider determines that telehealth is not appropriate for your needs, you will be referred to in-person care.

Your responsibilities

You agree to be physically located in a state where your provider is licensed during each visit, to tell your provider your location at the start of each visit, to be in a private, safe place, and to provide an emergency contact and the address where you are located in case of an emergency during the visit.

Emergencies

Telehealth is not for emergencies. If you are experiencing a psychiatric or medical emergency, call or text 988, call 911, or go to the nearest emergency room. Your provider may contact emergency services on your behalf if there is concern for your immediate safety.

Privacy

Visits are conducted on a HIPAA-compliant video platform and are not recorded without your written permission. Your health information is protected as described in our Notice of Privacy Practices.

Prescriptions

Medications, including some controlled substances, may be prescribed by telehealth when appropriate under federal and state law. Your provider may require a prescription monitoring program check, laboratory testing, or a periodic in-person evaluation as a condition of continued prescribing.

Fees

You are responsible for copays, coinsurance, deductibles, or self-pay fees at the time of service. Missed appointments or cancellations with less than 24 hours notice may be charged a fee that is not covered by insurance.

Your rights

You may withhold or withdraw consent to telehealth at any time without affecting your right to future care. You may request in-person care alternatives, and you may request a copy of your records.