This consent is for all telehealth services provided to me by Metta Counseling.
Telehealth is the use of the internet to provide remote health care for clients. A healthcare professional will be communicating with me remotely via the internet using doxy.me web-based audio-video software (referred to in this form as telehealth appointment). Doxy.me only hosts the software and does not provide medical advice or information.
This telehealth appointment may be for diagnosis, continuity of care, treatment, testing, or consultation deemed necessary by my provider or me.
I understand that during a telehealth appointment:
- details of my medical history and personal health information may be discussed with me
- audio, video, or photo recordings containing medical details may be transmitted via secure channels and may become part of my permanent medical record
- all confidentiality protections granted by state and federal laws apply to this appointment
- industry-standard network and software security protocols are in place to protect the privacy of the communication and safeguard transmitted information against eavesdropping and corruption
- there may be security and privacy risks associated with internet-based communications
- there are limitations compared to in-person visits since I will not be in the same room as my provider
- either my provider or I can discontinue telehealth appointments if either feels that information obtained through remote communications is not adequate for diagnostic decision-making or providing care
- in addition to my provider named above, I will be informed of any other person who may be present during the appointment and have the right to have them leave the viewing and listening area
- to maintain my privacy, I need to ensure that my viewing and listening area is limited to me and any other person that has a need to participate during the virtual appointment
- due to the limitations of telehealth that are out of my control (such as an unreliable internet connections), I will call local authorities (9-1-1) to assist me with a medical emergency
- I have the right to omit or withhold specific details of my medical history that are personally sensitive
- my provider may advise me to seek immediate treatment or determine that there is a medical emergency and, as such, local authorities may be given my personal details to assist me
- the communication is privileged and confidential, and I will not record the audio or video
- I desire to engage in remote audio-visual communication with my healthcare provider
- I understand risks and benefits of Internet-based communication and that no results are guaranteed
- I acknowledge that if the healthcare provider believes that remote communication is insufficient for treatment, consultation, or evaluation, then I will be offered alternate services or options
- I understand that I may be responsible for co-payments, deductibles, or other charges
- I can ask direct questions to my healthcare provider, including details about the privacy policy
- If my questions are not answered to my satisfaction, I have the right to terminate the appointment
- I am at least 18 years of age