Atrium Neuropsychology Telehealth Informed Consent
Nature and purpose of telehealth. Telehealth is a real-time interactive audio and visual technology that enables psychologists to provide services remotely. You will not have to purchase a plan or provide your name when you “join” our online meeting. The goal of this particular telehealth service is to gather neuropsychological information and provide guidance to individuals in need.
Procedures and Technology: It is important to be on time. If you need to cancel or change your tele-appointment, you must notify me in advance by phone or email. Prior to starting services, your identity must be verified via photo ID. You must also verify your location. You will need a webcam or smart phone during the session. It is important to be in a quiet, private space that is free of distractions during the session. It is important to use a secure internet connection rather than public/free Wi-Fi. If possible, please use a headset to minimize distracting noises coming from another room. In case of a technical disruption, the provider will call your contact number as soon as possible.
Approximate length of the sessions. An initial meeting is expected to take 15 minutes. A full consultation session is expected to take approximately 60-90 minutes. A coaching session is expected to take approximately 60 minutes.
Risks. Risks of the telehealth session may include (but are not limited to) lack of reimbursement by your insurance company, interruptions and delays due to Internet connectivity problems, or a breach of information that is beyond my control. Clinical risks may include discomfort with virtual face-to-face versus in-person sessions, difficulties interpreting non-verbal communication, and importantly, limited access to immediate resources if risk of self-harm or harm to others becomes apparent. Together we will weigh the advantages against any potential risks prior to proceeding with the session, and will discuss the specifics of telehealth with you before using the technology. I am not responsible for any accident or injury that may occur during the session, though such events are not expected.
Limits of confidentiality. There are potential risks of teleconferencing that differ from in-person sessions. The technological system I use (doxy.me) meets HIPAA standards of encryption and privacy protection, but I cannot guarantee privacy. Therefore, I will review the importance of privacy at my location and the patient’s location. All individuals present for the virtual visit will be told to announce their presence to the provider and must have permission from the identified patient. I will confirm that nobody will record the session without permission. The session may include questions about history that many people consider personal.Information obtained during assessments is confidential and can ordinarily be released only with your written permission, as noted above. There are some special circumstances that can limit confidentiality including: a) a statement of intent to harm self or others; b) statements indicating harm or abuse of children or vulnerable adults, even if the survivor is yourself and even if the event occurred many years ago; and c) issuance of a subpoena from a court of law.
Fees. Patients are responsible for any and all fees for the session. Fees will be indicated on a formal fee agreement document. I do not accept insurance, but I can provide you with a bill that you may submit to your insurance company. Insurance may not cover these services, however.
Discussion and clarification of the consent form. If you have any questions regarding this consent form and wish to speak to me prior to signing, please don’t hesitate to ask.
Atrium Neuropsychology 