Telehealth Consent form - Colib

I hereby consent to participate in telehealth. I understand that telehealth is the practice of delivering health-related services via technology assisted media or other electronic means between a practitioner and a client who are located in two different locations. I understand that telehealth may include consultation, treatment, emails, or telephone conversations. I also understand that telehealth may involve the communication of my medical and/or mental health both orally and visually.

I understand the following with respect to teleheath:

1. I understand that I have the right to withdraw consent at any time without affecting my right to future care, services, or program benefits to which I would otherwise be entitled.
2. I understand that there are risks, benefits, and consequences associated with telehealth, including but not limited to, disruption of transmission by technology failures, interruption and/or breaches of confidentiality by unauthorized persons, and/or limited ability to respond to emergencies.
   
3. I understand that there will be no recording of any of the online sessions by either party. All information disclosed within sessions and written records pertaining to those sessions are confidential and may not be disclosed to anyone without written authorization, except where the disclosure is permitted and/or required by law.
4. I understand that the privacy laws that protect the confidentiality of my protected health information (PHI) also apply to telehealth unless an exception to confidentiality applies (i.e. mandatory reporting of child, elder, or vulnerable adult abuse; danger to self or others; I raise mental/emotional health as an issue in a legal proceeding).