Consent to Telehealth
TELEHEALTH CONSENT FORM
Cayaba’s telehealth services involve the use of two-way electronic communication to enable Cayaba’s providers to have a videoconference visit with you from a remote location. Cayaba’s providers may include doctors, nurse practitioners, licensed clinical social workers and/or other professional staff, and a medical assistant or nurse may visit your location in-person to take certain vital signs and coordinate the telehealth visit.
In the event that your telehealth visit for medical services is not scheduled with a physician, you may request that the visit be rescheduled with a physician. Please simply contact Cayaba by email at care@cayabacare or call our office at (267) 668-2256.
The information obtained during your telehealth visit may be used for diagnosis, therapy, follow-up, and/or your education, and may include any or all of the following:
- Patient medical records
- Medical images
- Live two-way audio and video
- Output data from medical devices and sound and video files
The electronic systems used by Cayaba incorporate network and software security protocols to protect the confidentiality of all patient information, and include measures to safeguard the data and ensure its integrity against intentional or unintentional corruption, such as encryption.
If you are receiving telepsychiatry services from Cayaba, your physician or nurse practitioner will be located in New Jersey or Pennsylvania. If you are a Medicaid participant, you may also choose to receive in-person face-to-face psychiatry services by notifying Cayaba in advance.
Your patient visit will not be recorded without your consent, and recording your visit is not a condition to receiving services from Cayaba.
BENEFITS OF TELEHEALTH SERVICES
- Telehealth can make accessing health care and social work services easier, more efficient, and less expensive.
- You can obtain health care and social work services at times that are convenient for you.
- You can interact with providers without the necessity of an in-office appointment.
POTENTIAL RISKS OF TELEHEALTH SERVICES
The potential risks associated with telehealth services include, but are not limited to, the following:
- The inability of your provider to conduct certain tests or assess vital signs in-person may in some cases prevent your provider from diagnosing or treating you or identifying that you need urgent medical care.
- Information transmitted over the videoconference system may not be sufficient or accurate (e.g. due to a poor connection or poor resolution of images) to allow for appropriate medical decision-making by your provider.
- Delays in medical evaluation and treatment could occur due to deficiencies or failures of electronic equipment.
- Although uncommon, security protocols of the videoconference system could fail, causing a breach of the privacy and security of your health information.
BY SIGNING THIS FORM, I UNDERSTAND AND CONSENT TO THE FOLLOWING:
- I understand that a telehealth visit is not the same as an in-person visit, because I will not be in the same room as my provider. I understand that in-person care is available to me.
- I understand that I must take reasonable steps to protect myself from unauthorized use of electronic communications by others, and that Cayaba is not responsible for breaches in confidentiality caused by an independent third party or myself. I agree to take the necessary steps to maintain privacy for the telehealth visit, such as conducting my visit in a private space.
- I understand that I may expect certain benefits from the use of telehealth services, such as those set forth above, but no results can be guaranteed or assured.
- I understand the potential risks of this technology, including interruptions, unauthorized access and technical difficulties.
- I understand that my provider or I can discontinue the telehealth visit if either of us determine that the videoconferencing connection is not adequate for the situation.
- I have the right to withhold or withdraw my consent to the use of telehealth services at any time during the course of any telehealth session with a Cayaba provider, without affecting the provision of future care or treatment by Cayaba.
- I understand that telehealth visits will be billed to my insurance carrier on file with Cayaba, but coverage for telehealth services can vary. If the services are not covered under my insurance plan, I agree that I will be responsible for payment in accordance with Cayaba’s Financial Agreement and Assignment of Benefits.
- I understand that my telehealth visit may require the attendance of a Cayaba medical assistant or nurse at my location, and consent to such medical assistant or nurse coming to my location and performing standard medical screening tasks in connection with my visit.
- Cayaba has given me the opportunity to sign a HIPAA Authorization Form to release the medical records from my telehealth visit to my primary care provider and/or any other health care provider I may direct.
- I understand that a telehealth visit should never be used for emergency communications, any of which should be directed to 911 or emergency services in my community. If I have a non-emergency request that is urgent in nature, I understand that I should call Cayaba at (267) 668-2256 to discuss.
I have read and understand the information above regarding telehealth services (including telepsychiatry services) from Cayaba, and all of my questions regarding telehealth services have been answered by Cayaba and/or my provider.
By signing, I acknowledge that I have read and understand this Telehealth Consent Form and consent to receiving telehealth and/or telepsychiatry services from Cayaba: