Telehealth Consent Form - eSignature


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Minnesota CarePartner
393 N. Dunlap St.
St. Paul, MN 55104
P: 612-289-5656 F: 651-925-0278

 

Minnesota CarePartner/Roots Recovery allows, under certain conditions, the use of Telemedicine technology for Therapy and Skills sessions at the provider’s discretion and with the patient/client's consent. Telemedicine is not intended to be a complete replacement for face-to-face sessions and face-to-face sessions are expected to remain the primary mode of service.

Acceptable Reasons for the use of telemedical include such things as: Severe weather or transportation barriers making it difficult to travel to your clinician’s office, having to remain in home due to ill child, public health crisis, having your ride cancel at the last minute, scheduling conflicts or being out of town.

Keep in mind, however, that there might be certain clinical, ethical, or legal factors that would preclude or limit the use of Telemedicine. Your provider will discuss these factors with you on a case-by-case basis.

If you agree to participate in some sessions through telemedicine, please be reassured that all the standard issues related to privacy and confidentiality will still apply. However, please be advised that telemedicine uses the internet, which is not as secure as the privacy of your provider’s office and certain service providers might store copies of videos. It is possible that communication might be intercepted (hacked) or otherwise compromised. Additionally, telemedicine being a relatively new format, the empirical evidence for its efficacy, while promising, is limited. 

Also, be aware that if you elect to not use telemedicine for therapy, this will not affect your ability to continue scheduling face-to-face sessions with your provider as available. Please ask your provider how telemedicine sessions factors into the no show, and late cancelation policy. 

 

I agree to engage in sessions through telemedicine. I am aware of the potential limitations to privacy, confidentiality, and service connections associated with telemedicine.

I agree that I will take responsibility to ensure that I am in a place that allows sufficient privacy when engaging in telemedicine and that I will take every precaution to ensure that my confidential health information is protected on my end of the telemedicine connection.

   

   

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Signature Certificate
Document name: Telehealth Consent Form - eSignature
lock iconUnique Document ID: 63fbe709c2fac32adc69a05059615d8fec6f4a1c
Timestamp Audit
August 30, 2021 1:54 pm CSTTelehealth Consent Form - eSignature Uploaded by Roots Recovery - rootsforms@mncarepartner.com IP 206.84.184.37