VIRGINIA INTEGRATIVE PSYCHIATRY, PC TELEMEDICINE CONSENT
Telemedicine/Telepsychiatry involves the use of electronic communication to enable health care providers at Virginia Integrative Psychiatry, PC (VIP) to provide diagnostic and treatment services to patients at another location. The purpose of using this technology is to improve access to patient care, particularly during the COVID pandemic. Providers may include physicians, physician assistants, nurse practitioners, registered nurses, medical assistants, health care students, and other healthcare providers who are part of the clinical care team. The laws that protect the privacy and confidentiality of health and care information also apply to Telemedicine/telepsychiatry. Information obtained during Telemedicine/telepsychiatry will not be given to anyone without consent except for the purposes of treatment, education, billing and healthcare operations. In the state of Virginia, telemedicine recommendations are detailed under Guidance Document 85-12. All VIP clinical staff are licensed to provide services in the state of Virginia.
Telemedicine/telepsychiatry requires transmission, via Internet or telecommunication device, of health information, which may include:
• Progress reports, assessment, or other intervention-related documents
• Videos, pictures, text messages, audio and any digital form of data
As with any Internet-based communication, I understand there is a risk of security breach. Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard data and ensure its integrity.
Individuals other than the clinical care team or consulting providers may also be present and have access to my information for the Telemedicine/telepsychiatry session. This is so they can operate or repair the video or audio equipment used. These persons will adhere to applicable privacy and security policies.
Telemedicine/telepsychiatry sessions may not always be possible. Disruptions of signals or problems with the Internet's infrastructure may cause broadcast and reception problems (e.g. poor picture or sound quality, dropped connections, audio interference) that prevent effective interaction between clinician(s), participant, patient or care team. If this happens, an in-person appointment may be required, and will be scheduled by VIP front desk staff.
By signing below, I hereby release and hold harmless Virginia Integrative Psychiatry, PC and all members of the VIP care team from any loss of data or information due to technical failures associated with the Telemedicine/telepsychiatry services. By signing below, I understand that I will be given information about test(s), treatment(s) and procedure(s), as applicable, including the benefits, risks, possible problems or complications, and alternate choices for my medical care through the Telemedicine/telepsychiatry visit.
By signing below, I understand that I have the right to withhold or withdraw consent to the use of Telemedicine/ telepsychiatry services at any time and request traditional in-person clinic services. In addition, clinical staff may determine that in-person services are required in order to diagnose and treat a condition. If in-person services are requested or required, I agree to assist VIP front desk staff in scheduling these services. I understand that if I withdraw my consent for Telemedicine/telepsychiatry, it will not affect future services or care benefits to which I am seeking.By signing below, I acknowledge all my questions have been answered to my satisfaction.
By signing below, I consent to use of Telemedicine/telepsychiatry according to the above terms and conditions.
By signing below, I certify that I am the legal representative of the participant or that I am the patient and am 18 years of age or older, or otherwise legally authorized to consent.
