Telehealth Informed Consent
Telehealth consultation means any contact between a client and a health care practitioner relating to the health care diagnosis or treatment of such client through telehealth. For the purposes of telehealth, a consultation includes any service delivered through telehealth.
Telehealth means the use of medical information electronically exchanged from one site to another, whether synchronously or asynchronously, to aid a health care practitioner in the diagnosis or treatment of a patient. Telehealth includes services originating from a patient’s home or any other location where such patient is located, asynchronous services involving the acquisition and storage of medical information at one site that is then forwarded to or retrieved by a health care practitioner at another site for medical evaluation, and telemonitoring.
Please be advised that alternative options to telehealth are available, including in-person services as long as the office is open for business. If telehealth is being offered due to office closures, other options such as in-person services may not be available. In this case, be advised that telehealth services are offered as an alternative out of convenience and are not required to continue with treatment.
All existing laws and protections for services received in-person also apply to telehealth, including: confidentiality of information; access to medical records; and dissemination of client identifiable information. Telehealth consultations with our office will not be recorded unless a separate informed consent is signed in advance. Only the provider and the client will be allowed to be present during the telehealth session.
Should there be an emergency or urgent situation at any time during or after the provision of telehealth, the client and/or provider will contact local emergency services as necessary. This could include but is not limited to, calling 911 or the Midplains Crisis Stabilization Unit at 308-385-5250. Should there be a disconnection of services at any time, the provider will work to contact the client to discuss options for continuing or rescheduling services as needed.
For a client who is a child receiving telehealth behavioral health services, an appropriately trained staff member or employee familiar with the child’s treatment plan or familiar with the child will be immediately available in person to the child receiving a telehealth behavioral consultation in order to attend to any urgent situation or emergency that may occur during the provision of such service. This requirement may be waived by the child’s parent or legal guardian with proper documentation. In cases in which there is a threat that the child may harm himself or herself or others, the provider will contact the parent or guardian to notify as well as emergency personnel services as necessary. These contacts could include but are not limited to, contacting the legal parent or guardian, calling 911, or the Midplains Crisis Stabilization Unit at 308-385-5250.
I agree and consent to participate in the services offered by providers employed by or associated with Grand Island Mental Health & Medical Clinic, LLC. This could include any or all of the following services from the time of intake to discharge: community support, behavioral health, and/or medical health care. I agree to release information regarding my treatment to all providers associated with Grand Island Mental Health & Medical Clinic to use as a benefit and resource to my overall treatment goals. I understand that I am consenting and agreeing only to those services that the provider(s) is qualified to provide within: (1) the scope of the provider’s license, certification, and training; or (2) the scope of license, certification, and training of the health care providers directly supervising the services received by the patient. If the patient is under the age of nineteen or unable to consent to treatment, I attest that I have legal custody of this individual and am authorized to initiate and consent for treatment and/or legally authorized to initiate and consent to treatment on behalf of this individual.