Here is an example of a Telehealth Informed Consent Agreement between you and your client. Use the contents of this example to help build your own agreement for your Practice. Be sure to check your state laws governing Telehealth services and incorporated any need information into your agreement.
Telehealth Informed Consent Agreement
[practice name, address, phone number and website address]
Overview
- You will need access to the certain technological services and tools to engage in Telehealth-based services with your provider.
- Telehealth has both benefits and risks, which you and your provider will be monitoring as you proceed with your work.
- It is possible that receiving services by Telehealth will turn out to be inappropriate for you, and that you and your provider may have to cease work by Telehealth-based services.
- You can stop working by Telehealth at any time without prejudice.
- You will need to participate in creating an appropriate space for your Telehealth health sessions · You will need to participate in making a plan for managing technology failures, mental health crises, and medical emergencies
- Your provider follows security best practices and legal standards in order to protect your health care information, but you will also need to participate in maintaining your own security and privacy
What is Telehealth?
- Telehealth means the provisioning of mental health services by a provider to a recipient of services where each person is in separate locations, and the services being delivered are over electronic media.
- Services delivered via Telehealth rely on a number of electronic, often Internet-based, technology tools. These tools can include videoconferencing software, telephony, email, text messaging, virtual environments and others. Our Practice uses HIPAA compliant Audio & Video features that are built into our Practice Management software program.
- You will need access to the Internet, a Microsoft Windows or Apple Mac compatible computer that has a built-in or attached video camera and microphone.
If you have any questions or concerns about the above tools, please address them directly to your provider so you can discuss their risks, benefits, and specific application to your treatment.
Benefits and Risks of Telehealth
Receiving services via Telehealth allows you to:
- Receive services when you are unable to travel to the service provider’s office
- Receive services in a fashion that may be more convenient and less prone to delays than in-person meetings.
- The unique characteristics of Telehealth health media may also help some people make improved progress on health goals that may not have been otherwise achievable without Telehealth health.
Receiving services via Telehealth has the following risks:
Telehealth health services can be impacted by technical failures, may introduce risks to your privacy, and may reduce your service provider’s ability to directly intervene in crises or emergencies. Here is a non-exhaustive list of examples:
Telehealth health services can be impacted by technical failures, may introduce risks to your privacy, and may reduce your service provider’s ability to directly intervene in crises or emergencies. Here is a non-exhaustive list of examples:
- Internet connections and cloud services could cease working or become too unstable to use
- Cloud-based service personnel, IT assistants, and malicious actors (“hackers”) may have the ability to access your private information that is transmitted or stored in the process of Telehealth health-based service delivery.
- Computer or smartphone hardware can have sudden failures or run out of power, or local power services can go out.
Interruptions may disrupt services at important moments, and your provider may be unable to reach you quickly or using the most effective tools. Your provider may also be unable to help you in-person.
There may be additional benefits and risks to Telehealth health services that arise from the lack of in-person contact or presence, the distance between you and your provider at the time of service, and the technological tools used to deliver services. Your provider will assess these potential benefits and risks, sometimes in collaboration with you, as your relationship progresses.
Assessing Telehealth’s Fit for You
Although it is well validated by research, service delivery via Telehealth health is not a good fit for every person. Your provider will continuously assess if working via Telehealth health is appropriate for your case. If it is not appropriate, your provider will help you find in-person providers with whom to continue services.
Please talk to your provider if you find the Telehealth health media so difficult to use that it distracts from the services being provided, if the medium causes trouble focusing on your services, or if there are any other reasons why the Telehealth health medium seems to be causing problems in receiving services. Raising your questions or concerns will not, by itself, result in termination of services. Bringing your concerns to your provider is often a part of the process.
You also have a right to stop receiving services by Telehealth health at any time without prejudice. If your provider also provides services in-person and you are reasonably able to access the provider’s in-person services, you will not be prevented from accessing those services if you choose to stop using Telehealth health.
Your Telehealth Health Environment
You will be responsible for creating a safe and confidential space during sessions. You should use a space that is free of other people and pets. It should also be difficult or impossible for people outside the space to see or hear your interactions with your provider during the session. It should be free of other distractions such as doorbells or telephones ringing. If you are unsure of how to do this, please ask your provider for assistance.
Our Communication Plan
At our first session, we will develop a plan for backup communications in case of technology failures and a plan for responding to emergencies and mental health crises. In addition to those plans, your provider has the following policies regarding communications:
There may be additional benefits and risks to Telehealth health services that arise from the lack of in-person contact or presence, the distance between you and your provider at the time of service, and the technological tools used to deliver services. Your provider will assess these potential benefits and risks, sometimes in collaboration with you, as your relationship progresses.
Assessing Telehealth’s Fit for You
Although it is well validated by research, service delivery via Telehealth health is not a good fit for every person. Your provider will continuously assess if working via Telehealth health is appropriate for your case. If it is not appropriate, your provider will help you find in-person providers with whom to continue services.
Please talk to your provider if you find the Telehealth health media so difficult to use that it distracts from the services being provided, if the medium causes trouble focusing on your services, or if there are any other reasons why the Telehealth health medium seems to be causing problems in receiving services. Raising your questions or concerns will not, by itself, result in termination of services. Bringing your concerns to your provider is often a part of the process.
You also have a right to stop receiving services by Telehealth health at any time without prejudice. If your provider also provides services in-person and you are reasonably able to access the provider’s in-person services, you will not be prevented from accessing those services if you choose to stop using Telehealth health.
Your Telehealth Health Environment
You will be responsible for creating a safe and confidential space during sessions. You should use a space that is free of other people and pets. It should also be difficult or impossible for people outside the space to see or hear your interactions with your provider during the session. It should be free of other distractions such as doorbells or telephones ringing. If you are unsure of how to do this, please ask your provider for assistance.
Our Communication Plan
At our first session, we will develop a plan for backup communications in case of technology failures and a plan for responding to emergencies and mental health crises. In addition to those plans, your provider has the following policies regarding communications:
- The best way to contact your provider between sessions is by telephone or text messaging. If contacting via text messaging be sure to state your name within the body of the message.
- Your provider will respond to your messages 24 business hours.Please note that your provider may not respond at all on weekends or holidays. Your provider may also respond sooner than stated in this policy. That does not mean they will always respond that quickly.
Our work is done primarily during scheduled appointments. Contact between sessions should be limited to:
- Confirming or changing appointment times
- Billing questions or issues
Please note that all textual messages you exchange with your provider, e.g. emails and text messages, my not be a secure method of communication and will become a part of your health record.
Your provider may coordinate care with one or more of your other providers. Your provider will use reasonable care to ensure that those communications are secure and that they safeguard your privacy.
Our Safety and Emergency Plan
As a recipient of Telehealth health-based services, you will need to participate in ensuring your safety during mental health crises, medical emergencies, and sessions that you have with your provider.
Your provider will require you to designate an emergency contact. You will need to provide permission for your provider to communicate with this person about your care during emergencies.
Your provider will also develop with you a plan for what to do during mental health crises and emergencies, and a plan for how to keep your space safe during sessions. It is important that you engage with your provider in the creation of these plans and that you follow them when you need to.
Your Security and Privacy
Except where otherwise noted, your provider employs software and hardware tools that adhere to security best practices and applicable legal standards for the purposes of protecting your privacy and ensuring that records of your health care services are not lost or damaged.
As with all things in Telehealth, however, you also have a role to play in maintaining your security. Please use reasonable security protocols to protect the privacy of your own health care information. For example: when communicating with your provider, use devices and service accounts that are protected by unique passwords that only you know. Also, use the secure tools that your provider has supplied for communications.
Recordings
Please do not record video or audio sessions without your provider’s consent. Making recordings can quickly and easily compromise your privacy and should be done so with great care. Your provider will not record video or audio sessions.