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Telemedicine Consent Form

Client Name: Client Date of Birth: Name of Person Signing Forms: Person Signing Forms is the:

Explanation of Telemedicine

Minnesota CarePartner/Roots Recovery allows, under certain conditions, the use of Telemedicine technology for Therapy sessions at the therapist’s discretion and with the patient/client consent. "Telemedicine" is a term that means the delivery of health care services via secured, two-way, audio-video connection where the recipient (you) and the provider (us) are at different locations. 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 therapy.

Acceptable Reasons for the use of telemedicine include such things as:

severe weather or transportation barriers making it difficult to travel to your therapists office;

having to remain in home due to your or a family member's illness;

having your ride cancel at the last minute;

scheduling conflicts;

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 therapist will discuss these factors with you on a case-by case basis.

If you agree to participate in some therapy 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 internet, which is not as secure as the privacy of your therapist’s office and certain services providers might store copies of videos. If it is possible that communication might be intercepted (hacked) or otherwise compromised. Additionally, telemedicine being a relatively new filed, 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 therapist. Please ask your particular therapist how telemedicine sessions factors into the no show, and late cancelation policy.

Attestation

By signing this document, I attest that:

I wish to engage in my therapy sessions through telemedicine;

I am aware of the potential limitations to privacy, confidentiality and service quality associated with telemedicine;

I will take responsibility to ensure that I am in a place that allows sufficient privacy when engaging in telemedicine;

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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January 16, 2020 1:39 pm CDT

Telemedicine Consent eSignature Uploaded by MInnesota CarePartner - referrals@mncarepartner.com IP 101.50.105.47, 127.0.0.1, 198.71.243.23, 0.0.0.0

January 16, 2020 2:22 pm CDT