Telehealth Consent

Good Neighbor Outpatient Services

  1. I understand that my mental health provider is able to see me using live videoconferencing, a process referred to as Telehealth.

  2. Good Neighbor has explained to me how the video conferencing technology will be used to for such a consultation. I understand that this consultation will not be exactly the same as a direct office visit due to the fact that I will not be in the same room as my health care provider.

  3. I understand there are potential risks to this technology, including interruptions, unauthorized access and technical difficulties. I understand that my health care provider(s) or myself can discontinue the Telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.

  4. I understand that my healthcare information may be shared with other Good Neighbor employees for scheduling and billing purposes. Others may also be present during the consultation other than my healthcare provider and consulting health care provider in order to operate the video equipment. Good Neighbor employees will all maintain confidentiality of the information obtained. 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/physical examination that are personally sensitive to me; (2) ask non-medical personnel to leave the Telehealth examination room; and/or (3) terminate the session at any time.

  5. I have had the alternatives to a Telehealth consultation explained to me, and in choosing to participate in a Telehealth session, I understand that some parts of the exam involving physical tests may be conducted by individuals at my location at the direction of the consulting healthcare provider.

  6. In an emergent consultation, I understand that the responsibility of the telemedicine consulting provider is to advise the local support staff and that the provider’s responsibility will conclude upon the termination of the video conference connection.

  7. I have read this document carefully or someone has explained it to me, and I understand the risks and benefits of the teleconferencing consultation.

  8. I have had my questions regarding the procedure explained and I hereby consent to participate in a telemedicine visit under the terms described herein.