I agree to receive medically necessary live, interactive video telehealth services from CenterPointe, who is located at a distant site location.
And I understand that:
a. I retain the right to refuse telehealth consultations at any time without affecting my/my childs right to future care or treatment and without risking the loss or withdrawal of any program benefits to which I would otherwise be entitled.
b. All existing confidentiality protections shall apply to my telehealth consultation.
c. I shall have access to all medical information resulting from the telehealth consultation, as provided by law.
d. Information from the telehealth service (images that can be identified as my child/mine or other medical information from the telehealth service) cannot be released to researchers or anyone else without my written consent.
e. If I decline telehealth services, other alternative options are available to me, including in-person services. These options are: in-person therapy once virus precautions are lifted or in-office sessions if I am symptom free.
f. I will be informed whether the telehealth consultation will be or will not be recorded.
g. I will be informed of all people who will be present at all sites during my telehealth service.
h. I retain the right to exclude anyone from either the originating or distant site.
i. I understand that this consent is valid for six months for follow-up telehealth services with this health care provider.
j. If/when I participate in groups, I agree to protect the confidentiality of all participants information. This includes the environment in which I conduct the telehealth session (ie. use of headphones, sessions in a private location without unauthorized participants).
k. I further understand that there are potential risks to telemedicine, including but not limited to, interruptions, unauthorized access, and technical difficulties. I understand that either the healthcare provider or I can discontinue my/my child’s telehealth visit if it is felt that the videoconferencing connections are not adequate for the situation. I have read this document carefully and my questions have been answered to my satisfaction. I consent to participate in telehealth as outlined above