Telemedicine/Teletherapy Consent Form
Telemedicine/Teletherapy involves the use of synchronous electronic communications to enable clinicians and patients/clients to work together remotely. Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.
Improved access to medical care by enabling a patient to remain in his/her office (or at a remote site)
More efficient medical evaluation and management.
Obtaining expertise of a distant specialist.
As with any medical procedure, there are potential risks associated with the use of telemedicine/teletherapy.
These risks include, but may not be limited to:
In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the physician and consultant(s);
Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment;
In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information;
In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reaction or other judgment error.
By signing below, I attest to and understand the following:
I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine/teletherapy, and that no information obtained in the use of telemedicine/teletherapy which identifies me will be disclosed to researchers or other entities without my consent.
I understand that I have the right to withhold or withdraw my consent to the use of telemedicine/teletherapy in the course of my care at any time, without affecting my right to future care or treatment.
I understand that a variety of alternative methods of medical care may be available to me, and that I may choose one or more of these at any time. My clinician has explained the alternatives to my satisfaction.
I understand that I may expect the anticipated benefits from the use of telemedicine/teletherapy in my care, but that no results can be guaranteed or assured.
CONSENT TO THE USE OF TELEMEDICINE/TELETHERAPY
I have read and understand the information provided above regarding telemedicine/teletherapy, have discussed it with my clinician or his/her assistants as may be designated, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telemedicine/teletherapy in my medical care, and hereby authorize my clinician to use telemedicine/teletherapy in the course of my diagnosis and treatment.
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR HEATLH INFORMATION IS IMPORTANT TO US.
OUR LEGAL DUTY
We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices that are described in this Notice while it is in effect. This Notice takes effect 05/01/2023 and will remain in effect until we replace it. We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law.
We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request.
You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.
USES AND DISCLOSURES OF HEALTH INFORMATION
We use and disclose health information about you for treatment, payment, and healthcare operations.
Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.
Payment: We may use and disclose your health information to obtain payment for services we provide to you.
Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operation includes quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating provider performance, conducting training programs, accreditation, certification, licensing, or credentialing activities.
Your Authorization: In addition to our use of your health information for treatment, payment, or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.
To your family and friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend, or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.
Persons Involved in Care: We may use or disclose health information to notify or assist in the notification of (including identifying or locating) a family member, your personal representative, or another person responsible for your care, of your location your general condition or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosure. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.
Marketing Health-Related Services: We will not use your health information for marketing
communications without your written authorization.
Required by Law: We may use or disclose your health information when we are required to do so by law.
Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.
National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials’ health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances.
Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters).
Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. (You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this Notice. If you request copies, we will charge you $0 for each page. $20 per hour for staff time locate and copy your health information, and postage if you want the copies mailed to you. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. I you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure).
Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).
Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. (You must make your request in writing). Your request must specify the alternative means or location and provide satisfactory explanation how payments will be handled under the alternative means or location you request.
Amendment: You have the right to request that we amend your health information. (Your request must be in writing, and it must explain why the information should be amended). We may deny your request under certain circumstances.
Electronic Notice: If you receive this Notice on our Web site or by electronic mail (e-mail), you are entitled to receive this Notice in written form.
QUESTIONS AND COMPLAINTS
If you want more information about our privacy practices or have questions or concerns, please contact us. If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use of disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice.
You also may submit a written complaint to the U.S. Department of Health and Human Services. We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.
Contact Officer: Dr. Taiye Osawe, DNP, PMHNP-BC
California Privacy Rights
If you are a California resident, California Civil Code Section 1798.83 permits you to request information regarding the disclosure of your personal information to third parties for the third parties’ direct marketing purposes. To make such a request, please send an email to firstname.lastname@example.org or write to us at:
19725 Sherman Way Suite 295-B
Winnetka, CA 91306
If you are a California resident under the age of 18, and a registered user of any site where this policy is posted, California Business and Professions Code Section 22581 permits you request and obtain removal of content or information you have publicly posted. To make such a request, please send an email with a detailed description of the specific content or information to email@example.com. Please be aware that such a request does not ensure complete or comprehensive removal of the content or information you have posted and that there may be circumstances in which the law does not require or allow removal even if requested.
What is Salvage Psychiatry?Salvage Psychiatry is a mental health psychiatry clinic that provides comprehensive psychiatric services to individuals seeking help for mental health concerns. Our experienced team of professionals such as Nurse Practitioners, Psychiatrists, Therapists etc. offer physical and virtual consultations, evaluations, and personalized treatment plans.
How do I schedule an appointment with Salvage Psychiatry?Scheduling an appointment with Salvage Psychiatry is easy. You must review and sign the Consent Form prior to booking your appointment. Upon booking please fill in your details, including your preferred date and time, and our team of experts will get back to you to confirm your appointment.
What types of mental health conditions does Salvage Psychiatry treat or manage?Salvage Psychiatry specializes in treating or managing a wide range of mental health conditions, including but are not limited to Anxiety, Depression, Attention-deficit/hyperactivity Disorder (ADHD), Post-traumatic Stress Disorder (PTSD), Bipolar Disorder, Schizophrenia, Schizoaffective Disorder, Substance Abuse Disorder, and Sleep Disorder.
How long is a typical appointment at Salvage Psychiatry?The duration of appointments at Salvage Psychiatry can vary depending on your specific needs and concerns. On average, an initial evaluation may take around 60 to 90 minutes, while follow-up appointments usually last 30 to 45 minutes. However, our providers prioritize providing comprehensive care and will allocate the necessary time for each patient.
How qualified are the psychiatric mental health providers at Salvage Psychiatry?The team of experts at Salvage Psychiatry are highly qualified and experienced in their field. They have undergone rigorous training in psychiatry and mental health experts are licensed professionals. Additionally, our professionals stay updated with the latest research and evidence-based treatment modalities to provide the best possible care to our patients.
Can Salvage Psychiatry prescribe medication?Yes, our nurse practitioners and psychiatrists at Salvage Psychiatry are licensed medical professionals who can prescribe medication when necessary. They will evaluate your condition, discuss treatment options, and if appropriate, prescribe medication as part of your personalized treatment plan.
Is Salvage Psychiatry suitable for emergency or crisis situations?No, Salvage Psychiatry is not suitable for emergency or crisis situations. If you are experiencing a mental health emergency or immediate danger to yourself or others, please contact your local emergency services or go to the nearest emergency room.
How much does it cost to receive services from Salvage Psychiatry?The cost of services at Salvage Psychiatry can vary depending on the type and duration of the appointment. We strive to provide affordable and accessible mental health care. Please visit our website or contact our team directly for detailed pricing information and payment options.
Does Salvage Psychiatry accept insurance?Salvage Psychiatry works with a variety of insurance providers. We recommend contacting your insurance company to understand the specific coverage and reimbursement options available to you. Our team can provide you with the necessary documentation for reimbursement purposes.
Is my personal information kept confidential at Salvage Psychiatry?Yes, at Salvage Psychiatry, we prioritize the confidentiality and privacy of our patients. We adhere to strict privacy regulations and employ secure technology platforms to protect your personal information. Our team maintains confidentiality in accordance with legal and ethical guidelines.
Can I receive prescriptions through Salvage Psychiatry?Yes, if deemed necessary by your nurse practitioners or psychiatrists, you can receive prescriptions for psychiatric medications through Salvage Psychiatry. Our practitioners carefully evaluate each patient's needs and develop personalized treatment plans, which may include medication management.
What if I need urgent help outside of my scheduled appointments?If you are experiencing a mental health emergency, it's important to seek immediate help. While Salvage Psychiatry does not provide emergency services, we encourage you to contact emergency services in your state or visit the nearest emergency room in your city for immediate assistance.
Can Salvage Psychiatry provide therapy or counseling services?While Salvage Psychiatry primarily focuses on psychiatric services, we understand the importance of therapy as part of a comprehensive treatment plan. If deemed beneficial, our nurse practitioners or psychiatrists may recommend and coordinate therapy services with qualified therapists or psychologists as part of your overall care.
How and when can I contact Salvage Psychiatry?You may reach out to us through any of the following points of contact: Office: (818) 337-9072 Toll Free: (888) 988-4867 Fax: (888) 988-4867 Email: firstname.lastname@example.org Locations: 19725 Sherman Way Suite 295-B Winnetka, CA 91306 8880 Benson Ave Suite 125 San Bernardino, CA 91765