Informed Consent for Telehealth Services

Telehealth involves the use of electronic
communications to enable healthcare providers at
different locations to share individual patient medical
information for the purpose of improving patient care.
Telehealth services offered by NowPsych, P.L.L.C..
(“NowPsych”) may also include chart review, remote
prescribing, appointment scheduling, health
information sharing, and non-clinical services, such as
patient education. The information you provide may
be used for diagnosis, therapy, follow-up and/or
patient education, and may include any combination of
the following: (1) health records and test results; (2)
images and asynchronous communications; (3) live
two-way audio and video; (4) interactive audio with
store and forward; and (5) output data from medical
devices and sound and video files.
The electronic communication systems we use will
incorporate network and software security protocols to
protect the confidentiality of patient identification and
imaging data and will include measures to safeguard
the data and to ensure its integrity against intentional
or unintentional corruption.
NowPsych physicians (our “providers”) are an addition
to, and not a replacement for, your primary care
physician. Responsibility for your overall medical care
should remain with your local primary care doctor, if
you have one, and we strongly encourage you to
locate one if you do not.
Expected Benefits:
 Improved access to care by enabling you to
remain in your home while the NowPsych
provider consults and obtains test results at
distant/other sites.
 More efficient care evaluation and management.
 Obtaining expertise of a specialist as appropriate.
Possible Risks:
 Delays in evaluation and treatment could occur
due to deficiencies or failures of the equipment
and technologies.
 In rare events, our provider may determine that
the transmitted information is of inadequate
quality, thus necessitating a rescheduled
telehealth consult or a meeting with your local
primary care doctor.
 In very rare events, security protocols could fail,
causing a breach of privacy of personal medical
information.

 

 In rare events, a lack of access to complete
medical records may result in adverse drug
interactions or allergic reactions or other
judgment errors.
If you need to receive follow-up care, assistance in the
event of an adverse reaction to the treatment, or in the
event of an inability to communicate as a result of a
technological or equipment failure, please contact
NowPsych at contact@nowpsych.com
By checking the box associated with “Informed
Consent”, you acknowledge that you understand and
agree with the following:

 

  1. I hereby consent to receiving NowPsych’s
    services via telehealth technologies. I
    understand that NowPsych and its providers
    offer telehealth-based medical services, but
    that these services do not replace the
    relationship between me and my primary care
    doctor. I also understand it is up to the
    NowPsych provider to determine whether or
    not my specific clinical needs are appropriate
    for a telehealth encounter.
  2. I have been given an opportunity to select a
    provider from NowPsych prior to the consult,
    including a review of the provider’s credentials.
  3. I understand that federal and state law requires
    health care providers to protect the privacy and
    the security of health information. I understand
    that NowPsych will take steps to make sure
    that my health information is not seen by
    anyone who should not see it. I understand
    that telehealth may involve electronic
    communication of my personal medical
    information to other health practitioners who
    may be located in other areas, including out of
    state.
  4. I understand there is a risk of technical failures
    during the telehealth encounter beyond the
    control of NowPsych. I agree to hold harmless
    NowPsych for delays in evaluation or for
    information lost due to such technical failures.
  5. I understand that I have the right to withhold or
    withdraw my consent to the use of telehealth in
    the course of my care at any time, without
    affecting my right to future care or treatment. I
    understand that I may suspend or terminate

 

use of the telehealth services at any time for
any reason or for no reason. I understand that
if I am experiencing a medical emergency, that
I will be directed to dial 9-1-1 immediately and
that the NowPsych providers are not able to
connect me directly to any local emergency
services.

 

6. I understand that alternatives to telehealth
consultation, such as in-person services are
available to me, and in choosing to participate
in a telehealth consultation, I understand that
some parts of the services involving tests may
be conducted by individuals at my location, or
at a testing facility, at the direction of the
NowPsych provider (e.g., labs or bloodwork).

 

7. I understand that I may expect the anticipated
benefits from the use of telehealth in my care,
but that no results can be guaranteed or
assured.

 

8. I understand that my healthcare information
may be shared with other individuals for
scheduling and billing purposes. Persons may
be present during the consultation other than
the NowPsych provider in order to operate the
telehealth technologies. I further understand
that I will be informed of their presence in the
consultation and thus will have the right to
request the following: (1) omit specific details
of my medical history/examination that are
personally sensitive to me; (2) ask non-medical
personnel to leave the telehealth examination;
and/or (3) terminate the consultation at any
time.

 

9. I understand that I will not be prescribed any
narcotics for pain, nor is there any guarantee
that I will be given a prescription at all.

 

10. I understand that if I participate in a
consultation, that I have the right to request a
copy of my medical records which will be
provided to me at reasonable cost of
preparation, shipping and delivery.

 

Patient Consent
I have read this document carefully, and understand
the risks and benefits of the telehealth consultation
and have had my questions regarding the procedure
explained and I hereby give my informed consent to
participate in a telehealth consultation under the terms
described herein.

 

  1.