10-Telepsychiatry Consent Form.pdf

I have been asked by my health care provider to receive telemedicine services. This will be done with the Harris County Community Supervision and Corrections Department and its agents. The purpose is to assess and/or treat my psychiatric condition. This is done through a two-way audio/video link up with a health care provider.

I understand that:

1. I, my health care provider, or both of us will talk through the audio/video link.

2. I can ask that the exam and/or audio/video link be stopped at any time.

3. The potential risks and benefits have been discussed with me. I understand these may include (but are not limited to):

Potential Benefits:

• Increased accessibility to mental health care and to specialty services.

• Convenience for me.

Potential Risks:

• Interruption or disconnection of the audio/video link.

• A picture that is not clear enough to meet the needs of the evaluation.

• Delays in medical evaluation and treatment may occur due to deficiencies or failures of the equipment.

• There is a small chance that someone could tap into this session, if security protocols fail.

• A lack of access to all the information that might be available in a face to face visit.

This could lead to errors in medical decision making.

4. If any of these risks occur, or if the distant site provider determines there is a reason for me not to participate, then the telemedicine or telehealth service might need to be stopped. If the service is stopped for any reason, the staff at my location will work with me to develop a follow up plan.

5. I authorize the release of any relevant medical information that pertains to me to the Harris County Community Supervision and Corrections Department and its agents. This information may include my name, age, birth date, or other information that is necessary to conduct this telemedicine or telehealth services.

6. I understand that this service will become part of my medical record kept by the Harris County Community Supervision and Corrections Department and its agents.

7. I understand that I must give my informed consent to participate in this service.

8. I acknowledge that I have received a Notice of Privacy Practices.

9. NOTICE CONCERNING COMPLAINTS, Complaint about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, acupuncturists, and surgical assistants may be reported for investigation at the following address: Texas Medical Board, Attention:

Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768- 2018. Assistance in filing a complaint is available by calling the following telephone number: 1-800- 201-9353. For more information, please visit our website at www.tmb.state.tx.us.

I certify that this form has been fully explained to me. I have read it or have had it read to me. I understand its contents, and I give my consent to receive telemedicine and telehealth services.

Name: Case #:

Signature of Individual/Patient or Legal Authorized Representative Date

Name of Legally Authorized Representative (LAR)

LAR's Relationship to Individual/Patient (attach supporting documentation):

Signature of Staff Completing Consent/Title Date

PATIENT CONSENT FOR TELEMEDICINE AND TELEHEALTH

SERVICES

Patient Name:

Medical Record No:

1) I understand that my health care provider wishes me to engage in a telemedicine consultation.

2) My health care provider has explained to me how the video conferencing technology will be used to affect such a consultation will not be the same as a direct patient/health care provider visit due to the fact that I will not be in the same room as my health care provider.

3) 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 telemedicine consultation if it is felt that the videoconferencing connections are not adequate for the situation.

4) I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Others may also be present during the consultation other than my health care provider and consulting health care provider in order to operate the video equipment. The above-mentioned people will all maintain confidentiality of the information obtained. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/physical examination that are personally sensitive to me; (2) ask non‐medical personnel to leave the telemedicine examination room: and or (3) terminate the consultation at any time.

5) I have had the alternatives to a telemedicine consultation explained to me, and in choosing to participate in a telemedicine consultation. I understand that some parts of the exam involving physical tests may be conducted by individuals at my location at the direction of the consulting health care provider.

6) In an emergent consultation, I understand that the responsibility of the telemedicine consulting specialist is to advise my local practitioner, and that the specialist’s responsibility will conclude upon the termination of the video conference connection.

7) I have had a direct conversation with my doctor, during which I had the opportunity to ask questions in regard to 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.

By signing this form, I certify:

• That I have read or had this form read and/or had this form explained to me

• 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.

Patient’s/parent/guardian signature Date Time

Witness signature Date Time