Addendum to Patient Consent Agreement
This addendum discusses risks and benefits of telehealth videoconferenced consultation. Please have your attorney review it carefully.
I, the undersigned, or his or her designee(s), agree to participate in videoconferenced consultation with—————. This means that I authorize information related to my medical and mental health care to be electronically transmitted in the form of images and data through an interactive video connection to and from the abovenamed mental health care provider, other persons involved in my health care, and the staff operating the consultation equipment. I understand that I will be informed of the identities of all parties present during the consultation and of their purpose for attending the consultation.
My health care provider has explained how the telehealth consultation(s) is performed and how it will be used for my treatment. My health care provider has also explained how the consultation(s) will differ from in-person services, including but not limited to emotional reactions that may be generated by the technology. In brief, I understand that my mental health care provider ( “provider”) will not be physically in my presence. Instead, we will see and hear each other electronically. Some information my provider would ordinarily get in fact-to-face consultation may not be available in teleconsultation. My provider will be unable to touch me or to render any emergency assistance. I understand that telehealth consultation(s) are a new form of treatment, in an area not yet fully validated by research, and that they have potential risks, including the possibility that the technology will fail before or during the consultation, that the transmitted information in any form will be unclear or inadequate for proper use in the consultation(s), and that the information will be intercepted by an unauthorized party(s).
I understand that a physical examination may be performed by individuals at my location at the request of the consulting provider. I authorize the release of any information pertaining to me determined by the above-named health care providers or by my insurance carrier to be relevant to the consultation(s) or processing of insurance claims, including but not limited to my name, Social Security number, birth date, and clinical or medical record information.