Telehealth Release

The purpose of this document is to obtain consent for Telehealth Services with Heidi Miller Speech & Associates. In order to maintain care under certain circumstances, we may offer individual or group sessions, and assessments via telehealth service. Telehealth service is the delivery of healthcare services when the therapist and patient are not in the same physical location/site through the use of various technology. This could include video sessions via telehealth software on a computer or tablet, or phone sessions.

Risks/Benefits of Telehealth Sessions
Generally speaking, the risks and benefits of telehealth are similar to those of in-person sessions. However, there are additional risks. First, we will use secure platform, Zoom, with industry-standard encryption and security, but there is no way to guarantee that this software is completely fail-proof. As with any technology, there is a chance of a security breach that would affect the privacy of personal and/or medical information. Second, since you will be completing sessions in another location, we cannot guarantee the same level of privacy or the quiet environment that you would have in our clinic. This means that you are responsible for making sure that you are in a private area where disruptions (e.g., others coming into the room or hearing what you say in another room) are minimized as much as possible.

Since this may be different than the type of sessions with which you are familiar, it is important that you understand, acknowledge, and agree to the following statements
Please check each:
- You understand that you have agreed to engage in a telehealth encounter for yourself/your child that will contain personal identifying information as well as protected health information
- You understand that the therapist/assessor will be at a different location from you.
- You understand that you have the right to withhold or withdraw your consent to the use of telehealth services at any time in the course of your care, without affecting your right to future care or treatment.
- You have been informed of and accept the potential risks associated with telehealth, such as failure of security protocols that may cause a breach of privacy of personal and/or medical information.
- You understand that the laws that protect the privacy and the confidentiality of medical information also apply to telehealth, and that no information obtained in the use of telehealth which identifies you will be disclosed to other entities without your consent or as may be allowed by law.
- You have been given the opportunity to ask your provider at Heidi Miller Speech and Associates, questions relative to your Telehealth encounter, security practices, technical specifications, and other related risks.
By signing this form, you certify:

• That you have read or had read and/or had this form explained to you;
• That you fully understand its contents including the risks and benefits of telehealth services
• That you have been given ample opportunity to ask questions and that any questions have been answered to your satisfaction.
Name
First Last
Your email address
I have read Telehealth Release and agree.
- Yes
Date
MM slash DD slash YYYY

Telehealth Release

Risks/Benefits of Telehealth Sessions

© HMS Inc. 2021 - All rights reserved.

Go To

Services

Contact