Telehealth Informed Consent

1. Nature of telehealth services

Telehealth is the delivery of health care services using interactive audio, video, or other electronic communications between a patient and a clinician who are not in the same physical location. Services delivered by telehealth may include psychiatric evaluation and diagnosis, treatment planning, prescribing and management of medication, ordering and interpretation of laboratory testing, therapeutic support, care coordination, and patient education. Telehealth may also include the secure electronic transmission of your medical information, images, or laboratory results to the Provider or, with your authorization, to other practitioners involved in your care.

2. Voluntary participation and right to withdraw

Your participation in telehealth is entirely voluntary. You may withhold or withdraw this Consent at any time, in writing or verbally during a visit, without affecting your right to future care, treatment, or benefits to which you are otherwise entitled. Withdrawal does not apply retroactively to services already rendered. You may also request that a specific portion of a telehealth encounter be discontinued at any time.

3. Expected benefits

• Access to specialty psychiatric care without the need to travel.
• Greater scheduling flexibility and reduced time away from work or family.
• Care received in a familiar, private environment of your choosing.
• Continuity of care when in-person visits are impractical or unavailable.

4. Potential risks, limitations, and consequences

• Technology failure. Delays, interruptions, poor audio or video quality, or complete loss of connection may occur and may disrupt or delay evaluation and treatment.
• Limited physical examination. The Provider cannot perform hands-on physical examination. Clinical information available in person may be unavailable or incomplete, which in rare cases could lead to a delayed or inaccurate diagnosis, a delay in treatment, or the need for additional in-person evaluation.
• Security. Although the Provider uses HIPAA-compliant, encrypted platforms and reasonable administrative, physical, and technical safeguards, no electronic transmission or storage of information can be guaranteed to be completely secure.
• Suitability. In some circumstances telehealth is not clinically appropriate. The Provider may determine at any time that your condition requires in-person evaluation, laboratory or imaging studies, a higher level of care, or emergency services, and may decline to continue treatment by telehealth on that basis.

5. Alternatives

Alternatives to telehealth include in-person evaluation and treatment with another qualified clinician in your area, care through a community mental health center, or care through a hospital or urgent-care setting. You understand that you may choose an in-person alternative at any time.

6. Licensure, patient location, and identity verification

Telehealth services may be provided only when you are physically located in a state in which the Provider holds an active license at the time of the appointment. You agree to disclose your exact physical location at the beginning of each visit and to notify the Provider immediately if it changes during a visit. You agree not to misrepresent your location. If you are located outside a state in which the Provider is licensed, the visit may be cancelled without refund of any late-cancellation fee. You further agree to verify your identity upon request, including by presenting government-issued photo identification.

7. Emergencies and crisis care

Telehealth is not an emergency service and the Provider is not available for emergencies. If you are experiencing a psychiatric or medical emergency, are in immediate danger, or are having thoughts of harming yourself or another person, call 911, go to your nearest emergency department, or call or text 988 to reach the Suicide & Crisis Lifeline. You agree to provide an emergency contact and the address of your physical location at each visit so that emergency services may be dispatched if necessary, and you consent to the Provider contacting emergency services or your emergency contact if the Provider reasonably believes you or another person is at risk of imminent harm.

8. Confidentiality and privacy

Information disclosed during a telehealth visit is confidential and protected by the same federal and state laws that protect an in-person visit, including HIPAA and, where applicable, 42 CFR Part 2. Exceptions include suspected abuse or neglect of a child, elderly person, or vulnerable adult; a serious threat of harm to yourself or an identifiable other; a valid court order or subpoena; and other disclosures required or permitted by law.

You agree that you will not record any portion of a telehealth visit without the Provider’s prior written permission, and the Provider will not record without yours. You are responsible for securing a private setting on your end and for the security of the device, network, and email account you use.

9. Prescribing, controlled substances, and laboratory testing

Prescriptions are issued at the Provider’s clinical discretion and only when clinically appropriate. Prescribing of controlled substances by telehealth is governed by federal and state law, may require an in-person evaluation, may be restricted or unavailable, and is never guaranteed. The Provider may review state prescription drug monitoring program data and may require laboratory testing, prior records, or collateral information as a condition of prescribing. You are responsible for the cost of any laboratory work unless otherwise stated, and for completing recommended testing and follow-up.

10. Financial responsibility

This is a private-pay practice. You are financially responsible for all services rendered, in accordance with the fee schedule and cancellation policy provided to you. The Provider does not bill insurance; a superbill may be furnished on request, and reimbursement is not guaranteed. You have the right to a Good Faith Estimate of expected charges under the No Surprises Act.

11. Medical records and communication

Documentation of telehealth encounters is maintained in your medical record on the same terms as in-person care, and you may request access to it as provided by law. Email, text message, and telephone are used for scheduling and brief administrative matters only; they are not monitored continuously, are not appropriate for clinical or urgent concerns, and carry an inherent risk of interception. By providing your email address or mobile number, you consent to non-urgent communication through those channels.

12. No guarantee of outcome

You understand that the practice of medicine and mental health care is not an exact science and that no guarantee or warranty has been made to you regarding the result of any evaluation, treatment, or laboratory interpretation delivered by telehealth.

13. Acknowledgment and agreement

By signing the form, you certify that you have read this Consent in its entirety or it has been read to you; that the terms and the risks, benefits, and alternatives of telehealth have been explained to you in language you understand; that your questions have been answered; and that you knowingly and voluntarily consent to receive health care services by telehealth from the Provider. This Consent remains in effect for the duration of the treatment relationship unless withdrawn in writing.

14. Signatures

Signature lines for the patient, and for a parent or legal guardian when the patient is a minor, appear on the final page of the downloadable form.

Questions

Questions about this Consent can be directed to care@myrootcausenp.com.