* Required Information
  • I understand that my health care provider will engage in a Tele-health consultation with me.
  • My health care provider explained to me how the video conferencing technology that will be used to conduct a consultation will not be the same as a direct client/health care provider visit due to the fact that I will not be in the same room as my provider.
  • I understand that a Tele-health consultation has potential benefits including easier access to care and the convenience of meeting from a location of my choosing.
  • I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the Tele-health consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.
  • I have had a direct phone call conversation or video conferencing with my provider, during which I had the opportunity to ask questions regarding this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.
CONSENT TO USE THE TELEHEALTH BY DOXY.ME

Tele-health by Doxy.me the technology service we use to conduct Tele-health videoconferencing appointments. It is simple to use and there are no passwords required to log in. By signing this document, I acknowledge:

  • Tele-health by DOXY. ME is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911.
  • Though my provider and I may be in direct virtual contact through the Telehealth Service, neither Doxy.me nor the Tele-health Service provides any medical or healthcare services or advice including, but not limited to, emergency or urgent medical services.
  • The Tele-health by Doxy.me Service facilitates videoconferencing and is not responsible for the delivery of any healthcare, medical advice or care.
  • I do not assume that my provider has access to any or all of the technical information in the Tele-health by Doxy.me Service — or that such information is current, accurate or up-to-date. I will not rely on my health care provider to have any of this information in the Tele-health Doxy.me Service.
  • To maintain confidentiality, I will not share my Tele-health appointment link with anyone unauthorized to attend the appointment.

By signing this form, I certify:

That I have read or had this form read and/or had this form explained to me and that I fully understand its contents including the risks and benefits of the procedure(s).

That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.

CONSENT FOR TELEHEALTH CONSULTATION: BY SIGNING ON BELOW 1 AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.

Clear

  • I understand the concepts and conditions of informed consents, privacy and confidentiality.
  • I understand that I have the opportunity to discuss these concepts and conditions and to ask for clarification of parts which I am concerned about or do not fully understand.
  • I understand that I will be informed of the goals, expectations, procedures, benefits, and possible risks involved in the evaluation and treatment/therapy.
  • When using telemedicine services, technical issues could affect a session if there is a poor connection or non-functioning equipment.
  • I understand that all communication will be private, legally privileged, and confidential unless otherwise specified by the specific laws presented below or unless I provide my written consent with a specified release of information.
  • I also understand that there are no guarantees of positive outcome for the treatment/therapy.
  • If I have health insurance, I understand that I am responsible for confirming coverage and network status before I receive treatment and that I am responsible for payment when services are not covered by my plan.
  • I understand that applicable payment is due at the time-of-service that includes co-pays and self-payers.
  • I understand that I may ask questions by secure message within the client portal anytime.
  • I understand that I am responsible for privacy related to the technologies that I use to connect with Advanced Wellness Services and that I must password-protect those technologies to increase the security of my information.
  • I understand that I may be immediately discharged if my behavior is a threat to my provider(s) or the property of Advanced Wellness Services.
  • Upon such discharge, I understand that I will be given a list of alternate providers in my area from which I may choose a new provider for the continuation of my psychiatric care. I understand I am free to choose another provider that is not on the referral list and that I am responsible for making appointments immediately to prevent gaps in my care.
  • I understand that I may revoke consent and cancel treatment at will.
By signing this form, I verify that I understand and voluntarily accept all terms, services, practices, and policies explained in Advanced Wellness Services Patient Handbook and by my provider. I voluntarily consent to psychiatric and/or mental health services provided by Advanced Wellness Services providers. I understand and accept the scope of services, session structure, cancellation and no-show policy, contact information, and the use of technologies to provide treatment. I also confirm that I understand and voluntarily agree to the following:

Clear

I consent to the collection, use, storage, and processing of my personal and, where applicable, health-related information, including any data I submit on behalf of others, for the purpose of evaluating or fulfilling my request made through this form. I understand this will be handled in accordance with the Privacy Notice.