Telehealth Consent Form

Telehealth Services Description: Telehealth involves the delivery of healthcare services using electronic communications, information technology, or other means between a healthcare provider and a patient who are not in the same physical location. Telehealth may include, but is not limited to, psychiatric evaluations, therapy sessions, patient education, and medication management.

Benefits and Risks of Telehealth:

• Benefits: Increased accessibility to care, convenience, and often reduced waiting times.

• Risks: Potential limitations in diagnostic capability due to lack of physical examination, technical difficulties, and issues related to privacy and data security.

Patient Consent:

• I understand that I have the rights to confidentiality and privacy as outlined in the HIPAA Notice of Privacy Practices.

• I understand that the laws that protect the confidentiality of my medical information also apply to telehealth.

• I understand that I will be informed of all people present at each end of the telehealth interaction.

• I understand that I have the right to withdraw my consent to the use of telehealth in the course of my care at any time.

• I understand that I must be physically located in a state where Beal Wellness is licensed to provide care during my telehealth sessions. If my location changes, I agree to inform my provider immediately to ensure compliance with licensing regulations."

Data Security and Privacy:

• I understand that measures have been taken to safeguard the confidentiality of my health information but that there are risks inherent in electronic communication.

• I understand that Beal Wellness uses secure, encrypted video conferencing software compliant with HIPAA standards to deliver telehealth services.

Emergency Protocols:

• I understand the protocol for managing emergencies during a telehealth session and have provided my location at the beginning of each session for emergency purposes.

Patient Agreement: By signing this form, I acknowledge that I have read and understand the information provided above, and I consent to participate in telehealth services with Beal Wellness.