(video and/or audio consent)
(updated 3/23/2020)
Telehealth includes the delivery of behavioral health services using interactive technologies (audio, video, or other electronic communications) between a doctor and a patient that are not in the same physical location. The interactive technologies used in telepsychology incorporate network and software security protocols to protect the confidentiality of patient information transmitted via any electronic channel. This can be helpful in ensuring continuity of care if a patient moves to a different location, takes an extended vacation, is ill, or is otherwise unable to continue to meet in person (e.g. COVID-19, March 2020). Telepsychology, however, requires technical competence for both the patient and doctor to be helpful.
This TELEHEALTH: Informed Consent contains important information focusing on telehealth (including both psychotherapy and neuropsychological evaluations) using the Internet , telephone, and/or other electronic communication devices. Please read all carefully and let NBS-JAX know if you have any questions. Your signature below represents an agreement between you and your doctor.
As a patient receiving behavioral services through telehealth methods, I consent to participate in telepsychology, and I understand and agree to the following:
- There are potential benefits and risks of telehealth/video-conferencing (e.g. limits to patient confidentiality) that differ from in-person sessions.
- Confidentiality still applies for telehealth services, and nobody will record the session without the permission from the others person(s).
- The exchange of information will not be direct, and any paperwork exchanged will likely be provided through electronic means or through postal delivery.
- NBS-JAX doctors agree to use our video-conferencing platform via Microsoft Teams selected for our virtual sessions. There will be clear instructions about how you are to use the platform.
- You need to use a webcam, microphone, and/or smartphone during the session.
- It is important to be in a quiet, private space that is free of distractions (including cell phone or other devices) during the session.
- It is important to use a secure internet connection rather than public/free Wi-Fi.
- It is important to be on time. If you need to cancel or change your tele-appointment, you must notify our office via phone, text, or email ideally at least 24-hours PRIOR TO your scheduled telehealth appointment.
- NBS-JAX will set up a back-up plan (e.g., phone number where you can be reached) to restart the session or to reschedule it, in the event of technical problems.
- We need a safety plan that includes at least one emergency contact and the closest emergency room to your location, in the event of a crisis situation.
- If a need for direct, face-to-face services arises, it is your responsibility to contact your doctor at NBS-JAX through calling/emailing/texting. If your doctor is unavailable, you may need to contact your primary care provider. Alternatively, your doctor may determine that, due to certain circumstances, telehealth is no longer appropriate, and that in-person sessions should resume.
- You may decline any telehealth services at any time without jeopardizing my access to future care, services, or benefits.
- If you are not an adult, we need the permission of your parent or legal guardian (and his/her contact information) for you to participate in telehealth sessions.
- We recommend you confirm with your insurance company that the video sessions will be reimbursed; if they are not reimbursed, you are responsible for full payment.
- The laws and professional standards that apply to in-person behavioral services also apply to telehealth services. This document does not replace other agreements, contracts, or documentation of informed consent.
You may electronically sign and submit this form below. If you prefer not to submit electronically, you may download the form and submit it by fax, mail, or in person. Click here to download