INFORMED CONSENT

Tele-psychology/tele-medicine is the delivery of services using interactive audio or audiovisual electronic systems where the mental health professional and the patient are not in the same physical location. The interactive electronic systems used in tele-psychology/tele-medicine incorporate network and software security protocols to protect the confidentiality of patient information and audio and visual data. These protocols include measures to safeguard the data and to aid in protecting against intentional or unintentional corruption. However, these electronic systems may not comply with HIPAA, the federal medical privacy law. Potential benefits include increased accessibility to a mental health professional care and convenience.

My Rights

I have the right to withhold or withdraw my consent to the use of tele-psychology/tele-medicine at any time. The laws that protect the privacy and confidentiality of medical information also apply to tele-psychology/tele-medicine. I understand that the information disclosed by me during the course of my consultation is generally confidential, except under under certain circumstances where disclosure is required by the law (i.e., where there is a reasonable suspicion of child, dependent, or elder abuse or neglect; and where a client presents a danger to self, to others, to property, or is gravely disabled). The computer technology used by the assigned mental health professional is encrypted to prevent the unauthorized access to my private medical information, but I understand that there are risks and consequences from tele-psychology/tele-medicine, including, but not limited to, the possibility, despite reasonable efforts on the part of the mental health professional, that the transmission of my information could be disrupted or distorted by technical failures; the transmission of my information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons. I understand that tele-psychology/tele-medicine services may not be as complete as face-to-face services. If the mental health professional believes that I would be better served by another form of services, I will be advised who can provide such services in my area. I understand that while email may be used to communicate with the mental health professional, confidentiality of emails cannot be guaranteed. I understand that I have a right to access my medical information and copies of medical records in accordance with HIPAA privacy rules and applicable state law.

My Responsibilities

I understand that I am responsible for (1) providing the necessary computer, telecommunications equipment and internet access for my tele-psychology/tele-medicine sessions; (2) securing information on my computer; and (3) arranging a location with sufficient lighting and privacy that is free from distractions or intrusions for my tele-psychology/tele-medicine session.

Patient Consent To The Use of tele-psychology/tele-medicine

I have read and understand the information provided above regarding tele-psychology/tele-medicine, I hereby give my informed consent for the use of tele-psychology/tele-medicine in my care. I also hereby authorize my assigned doctor to disclose mental health treatment information and records obtained to my landlord and/or airlines.

I hereby authorize my assigned doctor to disclose mental health treatment information and records obtained in the course of mental assessment and/or treatment of Patient/Applicant, including, but not limited to, psychotherapist’s diagnosis. I hereby authorize my assigned doctor to disclose mental health treatment information and records obtained to my landlord and/or airlines upon request, including, but not limited to, psychotherapist’s diagnosis. I understand that I have a right to receive a copy of this authorization. I understand that any cancellation or modification of this authorization must be in writing. I understand that I have the right to revoke this authorization at any time unless Provider has taken action in reliance upon it. And, I also understand that such revocation must be in writing and received by Provider.

This disclosure of information and records authorized by Patient Patient/Applicant is required for the following purpose:
Results of Mental/Emotional Support Animal (ESA) assessment

The specific uses and limitations of the types of medical information to be discussed are as follows:
Results of Mental/Emotional Support Animal (ESA) assessment

Such disclosure shall be limited to the following specific types of information:
Results of Mental/Emotional Support Animal (ESA) assessment

Doctor shall not condition assessment/treatment upon Patient/Applicant signing this authorization and Patient/Applicant has the right to refuse to sign this form.

Patient/Applicant understands that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by the HIPAA privacy rule, although applicable USA laws may protect such information.