Telehealth Informed Consent
Specific Telehealth Informed Consent and Informed Consent for Mental Health and Medication Management Services
IMPORTANT NOTICE: DO NOT USE THESE SERVICES FOR EMERGENCY MEDICAL OR MENTAL HEALTH NEEDS. IF YOU ARE EXPERIENCING A MEDICAL OR MENTAL HEALTH EMERGENCY, YOU SHOULD DIAL “911” IMMEDIATELY AND/OR GO TO THE NEAREST EMERGENCY ROOM.
Telehealth is the use of two-way secure audio-visual electronic communications, information technology, or other means to enable a healthcare provider and a patient at different locations to communicate and share individual patient health information for the purpose of rendering or receiving clinical health care services. This “Telehealth Informed Consent” informs the patient (“I”, “patient,” “you,” or “your”) concerning the treatment methods, risks, and limitations of using a telehealth platform.
1. Services Provided.
Testa Psychiatry, LLC. (“Testa Psychiatry, LLC.”) provides certain non-clinical administrative and financial support services and licenses technology to their engaged healthcare providers (“Providers”). The Providers use Testa Psychiatry, LLC.’s technology platform to assist them in providing their patients various healthcare services, all of which are done via telehealth and some of which may include writing medically necessary prescriptions. Testa Psychiatry, LLC. does not diagnose or treat any medical condition, provide any healthcare service, or control or interfere with any medical or clinical decision made by a Provider. Testa Psychiatry, LLC. does not engage or supervise any Provider, each of whom are solely responsible for all healthcare decisions.
The telehealth services offered by the Providers may include a patient consultation, assessment, diagnosis, treatment recommendation, education, care management, prescription, and/or a referral to in-person care, as determined clinically appropriate by the Provider (the “Services”). Depending on your state laws, Providers may include physicians, physician assistants, nurse practitioners, registered professional nurses, psychiatrists, psychologists, psychiatric nurse practitioners, mental health counselors, professional counselors, therapists, therapy associates, clinical counselors, care counselors, clinical social workers, and other care providers.
2. Electronic Transmissions.
The types of electronic transmissions that may occur using the telehealth platform include, but are not limited to:
Appointment scheduling;
Completion, exchange, and review of medical intake forms and other clinically relevant information (for example: health records; images; output data from medical devices; sound and video files; diagnostic and/or lab test results) between you and your Provider via asynchronous and/or synchronous communications;
Two-way interactive audio in combination with store-and-forward communications; and/or two-way interactive audio and video interaction;
Treatment recommendations by your Provider based upon their review and exchange of clinical information;
Delivery of a consultation report with a diagnosis, treatment, and/or prescription recommendations, as your Provider deems clinically appropriate;
Prescription refill reminders (if applicable); and/or
Other electronic transmissions for the purpose of rendering clinical care to you.
3. Expected Benefits.
Benefits you may expect to receive from using telehealth services may include, but are not limited to:
Improved access to care and greater convenience by enabling you to remain in your preferred location while your Provider consults with you;
Lower cost;
Improved Provider-patient engagement;
Additional privacy with no public waiting rooms or receptionists calling out your name;
Convenient access to follow-up care. If you need to receive non-emergency follow-up care related to your treatment, please contact your Provider by sending a message through the platform portal; and/or
More efficient care evaluation and management.
4. Service Limitations.
PROVIDERS DO NOT ADDRESS MEDICAL OR MENTAL HEALTH EMERGENCIES. IF YOU BELIEVE YOU ARE EXPERIENCING A MEDICAL OR MENTAL HEALTH EMERGENCY, YOU SHOULD DIAL 9-1-1 AND/OR GO TO THE NEAREST EMERGENCY ROOM IMMEDIATELY. IF YOU ARE THINKING ABOUT SUICIDE OR IF YOU ARE CONSIDERING TAKING ACTIONS THAT MAY CAUSE HARM TO YOURSELF OR OTHERS, CALL THE NATIONAL SUICIDE PREVENTION HOTLINE ANYTIME AT 9-8-8 OR GO TO THE NEAREST EMERGENCY ROOM. YOU CAN ALSO USE THE 24/7 CRISIS TEXT LINE BY TEXTING “HOME” TO 741-741. PLEASE DO NOT ATTEMPT TO CONTACT TESTA PSYCHIATRY, LLC., ANY MEDICAL OR YOUR PROVIDER. AFTER RECEIVING EMERGENCY HEALTHCARE TREATMENT, YOU SHOULD VISIT YOUR LOCAL PRIMARY CARE PROVIDER.
The primary difference between telehealth and direct in-person service delivery is the inability to have direct, physical contact. Accordingly, some clinical needs may not be appropriate for a telehealth visit and your Provider, exercising their professional medical judgment, will make that determination.
Providers are an addition to, and not a replacement for, your local primary care provider. Responsibility for your overall medical care should remain with your local primary care provider if you have one, and we strongly encourage you to locate one if you do not.
The Providers do not have any in-person clinic locations.
5. Security Measures.
The electronic communication systems will incorporate network and software security protocols to protect the confidentiality of your patient identification and health and imaging information and will include commercially reasonable measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption. All the services delivered to you through telehealth will be delivered over a secure connection that complies with the requirements of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”).
6. Possible Risks.
Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment and technologies, or Provider availability.
In the event of an inability to communicate as a result of a technological or equipment failure, please contact us at support@Testapsychiatry.com.
In rare events, your Provider may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled telehealth consult or an in-person meeting with your local primary care doctor.
While the Providers are HIPAA-complaint, in very rare events, security protocols could fail, causing a breach of privacy of personal medical information.
During the initial screening, your Provider may determine that you should be seen in person, either by your primary care provider or in a recommended facility.
Your telehealth visit may not be covered by your medical insurance, however, we accept payment out-of-pocket (via credit or debit card), after which you may elect to contact your insurance company for reimbursement.
You may not be matched with a Provider that meets any or all of your preferences or requirements.
Your Provider may determine in the Provider’s own discretion and professional judgment that medication is not right for you and decide not to prescribe any medication.
7. Your Rights Regarding Telehealth.
You have the right to:
Refuse to participate in services delivered via telehealth and be made aware of alternatives and potential drawbacks of participating in a telehealth visit versus a face-to-face visit.
Be informed and made aware of the role of the Provider.
Be informed and made aware of the location of the Provider’s distant site and have all questions regarding the equipment, the technology, etc., addressed by your Provider.
Have the right to be informed of all parties who will be present during telehealth transmission.
Have the right to select another Provider and be notified that by selecting another Provider, there could be a delay in service and the potential need to travel for a face-to-face visit.
Depending on your state laws, your Provider may provide you with additional rights associated with telehealth.
8. Specific Informed Consent for Telehealth.
By signing below, you acknowledge that you understand and agree with the following:
I have read this document carefully and understand the risks and benefits of the telehealth consultation.
I give my informed consent to receive medical care and treatment by telehealth from the Providers.
I have the right to withhold or withdraw my consent to the use of telehealth at any time, without affecting my right to future care or treatment.
If I am experiencing a medical emergency, I have been directed to dial 9-1-1 immediately and that my Provider is not able to connect me directly to any local emergency services.
If I am thinking about suicide or if I am considering taking actions that may cause harm to myself or others, I have been directed to call 9-8-8 or to go to the nearest emergency room or to use the 24/7 crisis text line by texting “HOME” to 741-741.
I may elect to seek services from an unaffiliated medical group with in-person clinics as an alternative to receiving telehealth services.
I may expect the anticipated benefits from the use of telehealth in my care, but that no results can be guaranteed or assured.
Prior to the telehealth visit, I have been given an opportunity to review the Provider’s profile and credentials and to select a Provider I feel is appropriate for me.
Before the telehealth visit with my Provider begins, the Provider may explain additional rights and risks associated with telehealth. My Provider will also explain my diagnosis and its evidentiary basis, and the risks and benefits of various treatment options. I understand that I may ask my Provider questions regarding any aspect of the visit, and that I may at any time for any reason elect not to proceed with the telehealth visit.
I understand that someone other than my Provider might also be present during the consultation, including in order to operate the video equipment or provide translation services. If so, I understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (i) omit specific details of my medical history/physical examination that are personally sensitive to me; (ii) ask non-medical personnel to leave the telehealth examination room; and/or (iii) terminate the consultation at any time.
I understand that there is a risk of technical failures during the telehealth visit beyond the control of my Provider(s), and/or Testa Psychiatry, LLC.
In choosing to participate in a telehealth visit, I understand that some parts of the Services involving tests (e.g., labs or bloodwork) may be conducted at another location such as a testing facility, at the direction of my Provider.
It is necessary to provide my Provider a complete, accurate, and current medical history and that I understand that I can log into my Testa Psychiatry account at any time to access, review, amend, or request amendment of my health information. I understand that withholding or providing inaccurate information about my health and medical history in order to obtain treatment may result in harm to me, including, in some cases, death.
There is no guarantee that I will be issued a prescription, that the decision of whether a prescription is appropriate will be made solely in the professional judgment of my Provider, and that if my Provider issues a prescription, I have the right to select the pharmacy of my choice.
There is no guarantee that I will be treated by a Provider and that I may need to seek medical care and treatment in-person or from an alternative source. My Provider reserves the right to deny care for potential misuse of the Services or for any other reason if, in the professional judgment of my Provider, the provision of the Services is not medically or ethically appropriate.
Federal and state law requires health care providers to protect the privacy and the security of health information. I understand that the laws that protect privacy and the confidentiality of health information also apply to telehealth, and that information obtained in the use of telehealth, which identifies me, are subject to policies, procedures and practices adopted by the Providers that are designed to comply with HIPAA requirements and other applicable laws, and such laws govern which records resulting from the telehealth visit are part of my medical record.
The Providers will protect and take commercially reasonable steps to make sure that my health information is not seen by anyone who should not see it. I understand that telehealth may, at the Provider’s discretion, involve electronic communication of my personal health information to other health practitioners who may be located in other areas, including out of state, and that my health information may be shared with other individuals for scheduling and billing purposes. Dissemination of any patient identifiable images or information from the telehealth visit to researchers or other educational entities will not occur without my affirmative consent.
I have the right to request a copy of my medical records at any time. Requests for a personal copy for my own use or requests to have a copy sent to my designated health care provider can be made by emailing: support@testapsychiatry.com. I will not be charged for copies to be sent directly to my treating health care provider. Copies sent directly to me, for my own personal use, may have a reasonable cost of preparation, shipping, and delivery. I will be given an estimate of this cost before agreeing to pay.
I AGREE TO RELEASE AND HOLD HARMLESS TESTA PSYCHIATRY, LLC. AND THEIR AFFILIATES AND SUBSIDIARIES, AND EACH OF THEIR EMPLOYEES (INCLUDING PROVIDERS), CONTRACTORS, AGENTS, DIRECTORS, MEMBERS, MANAGERS, SHAREHOLDERS, OFFICERS, REPRESENTATIVES, ASSIGNS, PARENTS, PREDECESSORS, AND SUCCESSORS, FROM AND AGAINST ANY CLAIM, ACTIONS, PROCEEDINGS, DEMANDS, DAMAGES, LOSSES, LIABILITIES, SETTLEMENTS, COSTS AND EXPENSES, INCLUDING, WITHOUT LIMITATION, REASONABLE LEGAL AND ACCOUNTING FEES AND LITIGATION EXPENSES RESULTING OR ARISING FROM, OR ALLEGED TO RESULT OR ARISE FROM, DELAYS IN EVALUATION, INFORMATION LOST DUE TO TECHNICAL FAILURES AND/OR THE RISKS SET FORTH ABOVE.
9. Additional State-Specific Consents:
The following consents apply to patients accessing the Services for the purposes of participating in a telehealth consultation as required by the states listed below:
Georgia. You have been given clear, appropriate, accurate instructions on follow-up in the event of needed emergent care related to the treatment. (Ga. Comp. R. & Regs. 360-3-.07(a)(7)).
Relevant Board Contact Information:
Georgia Composite Medical Board
2 Peachtree Street, NW, 6th Floor, Atlanta, GA 30303-3465
Email: medbd@dch.ga.gov
Oregon. If you have a concern or complaint about the mental health professionals providing care to you, you may contact a board agency to assist you. You understand that the provider may ask if you need more detail. ORS 17-52-677.07
Relevant Board Contact Information:
The Board of Licensed Professional Counselors and Therapists
3218 Pringle Rd SE, #120, Salem, OR 97302-6312
Phone: (503) 378-5499 Email: lpct.board@state.or.us
Website: www.oregon.gov/OBLPCT
Washington. You understand the purposes of and resources available to you surrounding this treatment, including the right to refuse treatment, and your responsibility in choosing a provider and treatment that best suits your needs. RCW 18.19.060.
The information you share in psychotherapy is protected health information and is generally considered confidential by both Washington state law and federal regulations, with some limited exceptions (e.g., may be shared with another healthcare provider, required by subpoena). RCW 18.19.180.
Counselors practicing counseling for a fee must be credentialed with the department of health for the protection of the public health and safety. Credentialing of an individual with the department of health does not include a recognition of any practice standards, nor necessarily imply the effectiveness of any treatment. The purpose of the Counselor Credentialing Act, chapter 18.19 RCW, is to: (A) Provide protection for public health and safety; and (B) Empower the citizens of the state of Washington by providing a complaint process against those counselors who would commit acts of unprofessional conduct. Clients have the right to choose counselors who best suit their needs and purposes.
A copy of the acts of unprofessional conduct in RCW 18.130.180 can be found on the Washington State Legislature’s website at this address http://apps.leg.wa.gov/RCW/default.aspx?cite=18.130.180.
Relevant Board Contact Information:
Washington State Department of Health
Health Professions Quality Assurance
P.O. Box 47865 Olympia, WA 98504-7865
Phone: (360) 236-4700
10. Specific Informed Consent for Mental Health and Medication Management Services.
This “Specific Informed Consent for Mental Health and Medication Management Services” informs you of the treatment methods, risks, and limitations of accessing mental health and/or medication management services.
By signing below, you acknowledge that you understand and agree with the following:
Medication Management
Your Provider, exercising their independent professional medical judgment, might determine that medications may be indicated, which may occur prior to initiating therapy or when your symptoms are not responsive to therapy alone. When a mental illness markedly impacts your ability to work, maintain interpersonal relationships, or properly care for your basic needs, medication may offer much needed relief. Not everyone is a good candidate for medication therapy. Such therapy requires adherence to dosage, frequency, and follow-up. Before deciding to start medication, your Provider will consider your ability to adhere to medication treatment. Additionally, your Provider will discuss the risks, benefits, side effects, government warnings, and alternative treatments (which always includes not using medications) with you.
Consent for Treatment
This consent provides the Providers with your permission to perform reasonable and necessary mental health examinations, testing, treatment, case management, medication management, and other appropriate healthcare services as determined by your Provider. By signing below, you are agreeing that (1) you intend that this consent is continuing in nature even after a specific diagnosis and treatment recommendation, (2) you consent to treatment by any Provider you choose, (3) the consent will remain in effect until it is revoked in writing, and (4) you have the right to discuss your diagnosis and treatment with your Provider (including the purpose and potential risks and benefits).
Consent to Enroll In Automatic Medication Refill Program
By signing this Informed Consent for Mental Health and Medication Management Services, I am requesting and authorizing my selected pharmacy to refill all future Provider-authorized refills for any particular refill, for the number of times authorized or for the period authorized, without my request for a refill (the “Automatic Refill Program”). I acknowledge that I have the right to rescind or revoke my authorization to enroll in the Automatic Refill Program at any time by notifying my selected pharmacy or my Provider of such rescission or revocation.
By giving my signature or clicking the "I Consent" button below, I hereby confirm and attest that I have carefully read and understand the terms and conditions above, and I agree to this Telehealth Informed Consent and this Informed Consent for Mental Health and Medication Management Services, and to utilize telehealth services in the provision of care. I certify that I am the patient and am 18 years of age or older, or the legal representative of the patient, or otherwise legally authorized to consent. I understand that this informed consent will become a part of my medical record.
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Signature of Patient or Patient’s Legal Representative Date
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Relationship to Patient (if Patient’s Legal Representative)