Patient Consent to use of Telehealth Technology
Parallel Learning Behavioral Health, P.C., a Connecticut professional corporation (“Professional Corporation”), its affiliated health care providers, or other members of your care team (each, a “Provider”), may arrange for you to connect with Providers and/or provide you with professional services using asynchronous and/or synchronous telehealth technologies (“Telehealth Technology”). If you have questions about use of the Telehealth Technology itself and whether it is appropriate for your condition, the risks associated with using the Telehealth Technology, or the Provider’s credentials and professional background, please ask your Provider. In exchange for your use of the Telehealth Technology to receive care, you acknowledge and agree to the following terms and conditions of this informed consent (this “Consent”):
1. Use of Telehealth Technology. You understand and agree that:
● There are many benefits, but also risks, associated with receiving care via Telehealth Technology. Benefits include convenience, increased access, and the ability to receive care in your home. Risks are outlined in Section 2 below.
● Services provided through Telehealth Technology may include photographs and video recordings made of you and your child (or minor individual for whom you are a legal guardian). The photographs and video recordings will be used by Parallel staff to observe and evaluate your child’s Parallel provider. The photographs and video recordings will remain confidential and will not be shared outside of Parallel.
● The Provider will decide, in his or her sole discretion, whether it is appropriate to treat your condition using the Telehealth Technology. The Provider may request that you halt receiving care via Telehealth Technology and instead receive in-person care if the Provider deems appropriate.
● Services provided through Telehealth Technology may include behavioral health services, and you expressly agree to receive such services through Telehealth Technology.
● If you are a parent or legal guardian of a minor that is seeking to receive mental health treatment through Telehealth Technology, you agree that (1) you are providing this Consent on behalf of your minor child, and (2) you will verify your identity before any services are delivered to your minor child.
● Services provided through Telehealth Technology may involve electronic communication of your personal medical information to Providers that may be located in other areas, including out of state.
● Your Provider will protect the privacy and security of any personal medical information transmitted through Telehealth Technology in accordance with federal, state, and other applicable law.
● You have the right to request copies of your medical records, which may be provided electronically or in hard copy format at reasonable cost of preparation, shipping and delivery.
● The anticipated response time for electronic communications submitted through the Telehealth Technology varies and you accept any risk associated with the response time, including a delay in obtaining medical care.
● No warranty or guarantee has been made to you concerning any particular result related to your condition or diagnosis.
2. Risks Associated with Use of Telehealth Technology. You understand that use of the Telehealth Technology has risks associated with it, such as (1) information that you transmit through the Telehealth Technology may be insufficient to allow for appropriate decision-making by the Provider; (2) failures of equipment (e.g., servers, devices) or infrastructure (e.g., communications lines, power supply, software failures) may cause interruptions and delays in the provision of care and treatment, or loss of information; and (3) in rare events, security protocols could fail, causing unauthorized access to your health information. You acknowledge that, although Professional Corporation and its telehealth technology vendor strive to prevent unauthorized access to information about you through encryption of information transmitted by the Telehealth Technology and other security measures, Professional Corporation and its vendor cannot guarantee that your use of the Telehealth Technology and the information will be private or secure, and you consent to this risk. You understand and consent to the risks associated with your use of the Telehealth Technology.
3. Group Therapy. If you and a Provider decide to engage in group or couples therapy or any other group wellness or health offerings (collectively “Group Therapy”), you understand that information discussed in Group Therapy is for therapeutic purposes and is not intended for use in any legal proceedings involving Group Therapy participants. You agree not to subpoena the Provider to testify for or against other Group Therapy participants or provide records in court actions against other Group Therapy participants. You understand that anything any Group Therapy participant tells the Provider individually, whether on the phone or otherwise, may at the therapist’s discretion be shared with the other Group Therapy participants. You agree to share responsibility with the Provider for the therapy process, including goal setting and termination.
4. Accuracy of Information Submitted to the Provider. You acknowledge and agree that you are solely responsible for ensuring that the information submitted by you through the Telehealth Technology is accurate, complete and current at all times when you use the Telehealth Technology. You understand that the Provider will rely on this information to provide services to you.
5. Release and Waiver. You acknowledge and agree to limit, disclaim, and release Professional Corporation from liability in connection with the use of Telehealth Technology.
6. Expenses. You understand and agree that you may be responsible for the cost of certain professional fees associated with your use of the Telehealth Technology and the cost of any medications or supplies prescribed by the Provider, if applicable.
7. Other Legal Terms. This Consent cannot be amended except in writing by mutual agreement of Professional Corporation and you. If any provision is or becomes unenforceable or invalid, the other provisions will continue with the same effect.
8. Right to Revoke. You have the right to withhold or withdraw your consent to the use of Telehealth Technologies in the course of your care at any time, without affecting your right to future care or treatment. You may suspend or terminate access to the services at any time for any reason or for no reason in accordance with this Section 8. You understand that you can revoke this Consent by sending written notice using electronic mail to Professional Corporation at: [email protected] (“Revocation”). You agree that your Revocation must contain your name and your address. You also understand that your Revocation means that you are not permitted to receive care using Telehealth Technology. Your Revocaltion will be effective upon Professional Corporation’s receipt of your written notice, except that your Revocation will not have any effect on any action taken by the Provider in reliance on this Consent before Professional Corporation received your written notice of Revocation.