CONSENT TO USE TELE-PSYCHIATRY

 

I {patientName}, am physically located in {patientLocation148}, {state}.

At the beginning of each Telepsychiatry session, I will help my psychiatrist to complete a check-in to assess the suitability of using Telepsychiatry services by verifying my full name, my current location, my readiness to proceed, and whether I am in a situation conducive to private, uninterrupted communication. By signing this consent, I understand and agree:

1. My psychiatrist is located in and licensed by the State of California. My psychiatrist may not be able to prescribe medications for me and/or may not be able to assist me in an emergency situation when I am located in any other state or country. I may contact my psychiatrist for prescription(s)/refill(s) of routine psychiatric medication(s). If I require emergency care, I may call 911 or proceed to the nearest hospital emergency room for help. If I am having suicidal thoughts or making plans to harm myself, I can call the National Suicide Prevention Lifeline at 1-800-273- TALK (8255) for free 24-hour hotline support.

2. I submit to the exclusive jurisdiction of the California state superior courts and agree that any claim, lawsuit, or other legal proceeding arising out of or relating to the Telepsychiatry services provided by my psychiatrist will be brought solely and exclusively in California state superior courts. I also agree that the interpretation of this consent will be exclusively governed by and construed in accordance with the laws of California.

3. My psychiatrist believes that Telepsychiatry services are appropriate for my condition and that I would benefit from its use despite its risks and limitations. While I may expect anticipated benefits from the use of Telepsychiatry, no specific results can be guaranteed or assured.

4. If my psychiatrist believes at any time that another form of services (for example, a traditional in-person consultation) would be appropriate, he/she may discontinue Telepsychiatry services and schedule an in-person consultation or refer me to a healthcare provider in my area who can provide such services.

5. I have the right to withdraw consent to the use of Telepsychiatry services at any time.

6. I received an explanation of how the electronic communications technology will be used for the Telepsychiatry services. I am comfortable with using electronic communications technology to communicate with my provider and understand there are limitations to the technology which may require an in-person consultation.

7. I agree to have the necessary computer, equipment and internet access for my Telepsychiatry communications. I also agree to arrange for a location with sufficient lighting and privacy that is free from distractions or intrusions during my Telepsychiatry communications.

8. The laws that protect privacy and the confidentiality of my medical information also apply to Telepsychiatry. The medical information that is transmitted electronically from my provider to me will be encrypted during transmission and will be stored only by my provider. I understand the dissemination of any personally-identifiable images or information from the Telepsychiatry communication to unauthorized persons will not occur except as required by federal or California state law.

9. I understand my risks of a privacy violation increase substantially when I enter information on a public access computer, use a computer that is on a shared network, allow a computer to “autoremember” usernames and passwords, or use my work computer for personal communications. I also understand it is my responsibility to encrypt medical information I transmit electronically to my provider and my failure to use technical safeguards, such as encryption, increases my risks of a privacy violation.

10. I have the right to access my medical information and obtain copies of my medical records in accordance with California law.

11. I understand that the Telepsychiatry services provided to me will be billed to my health insurance company and that I will be billed for any patient responsibility as per my insurance.

12. I agree to provide signed credit card authorization or other means of payment for patient responisblity payments in order to provide Telepsychiatry services. 

I have read and understand the information provided in this Consent to Use of Telepsychiatry. I discussed any question I had with my psychiatrist and all of my questions were answered to my satisfaction.

 

In order to coordinate coverage of services, including Tele Psychiatry visits, we require patients to provide us with a valid credit card which we will charge following appointments for amounts owed for co-payments, deductibles, and co-insurance by patients for services rendered by your provider. In the event a patient misses or cancels an appointment without two business days’ notice, Sacramento NeuroPsych Associates will charge the appropriate fee pursuant to our cancellation policy to the cardholder’s credit card. Questions concerning charges can be directed to Sacramento NeuroPsych Associates Billing Department at (916) 473-2235.

Sacramento NeuroPsych Associates uses a third-party service providers to process credit card charges and to securely store patients’ credit card information on file as a convenient method of payment for any amounts not covered by patients’ insurance and for which patients are responsible for services rendered. Patients’ credit card information will be kept confidential and secure using patient payment solutions vendors.

I hereby authorize Sacramento NeuroPsych Associates to keep this credit card's information provided below on file and charge this credit card following office visits, from the first date of service, for any amounts owed for services rendered to {patientName} which are not covered by insurance, including co-pays, deductibles, and co-insurance. In addition, I authorize Sacramento NeuroPsych Associates to charge this credit card fees for No Show/Missed appointments/Late cancellations.

I understand that I may elect to receive receipts via mail or email for any amounts charged to my credit card by Sacramento NeuroPsych Associates.

I further understand that such amounts charged to my credit card will appear on my credit card statement.

I understand that this authorization is valid for one (1) year from the date written below unless I cancel this authorization by providing written notice to Sacramento NeuroPsych Associates.