TELEHEALTH INFORMED CONSENT

By signing this form, I understand and agree with the following:

I understand that telehealth/telemedicine requires the transmission of personal health information via internet and/or other electronic communication methods, for use in diagnosis, therapy, follow-up, and/or education. The personal health information transmitted may include but not be limited to:

  • Progress reports, assessments, or other intervention-related documents

  • Bio-physiological data

  • Videos, images, text messages, audio, and data in digital format.

I understand that:


  1. I have the right to withhold or withdraw consent to the use of telehealth/telemedicine services at any time and revert back to traditional in-person clinical services. I understand that if I withdraw my consent for telehealth/telemedicine, it will not affect any future services or care benefits to which I am entitled.


  2. The laws that protect privacy and the confidentiality of personal health information also apply to telehealth/telemedicine, and that no information obtained in the use of telehealth/telemedicine that identifies me will be disclosed to anyone without my consent except for the purposes of treatment, education, billing, and/or healthcare operations, unless an exception to confidentiality applies (i.e., mandatory reporting of child, elder, or vulnerable adult abuse, posing a danger to self or others, or my raising mental/emotional health as an issue in a legal proceeding). More information on confidentiality and its limits can be found in the Notice of Privacy Practices that was provided to you. 


  3. I have the right to inspect all information obtained and recorded in the course of a telehealth/telemedicine interaction, in accordance with applicable state laws, and that I may receive copies of this information for a reasonable fee.

I further understand that:

As with any internet-based communication, telehealth/telemedicine involves 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 the data and to ensure its integrity against intentional or unintentional corruption.

Telehealth/telemedicine 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, and/or audio interference) that prevent effective interaction between consulting clinician(s), participant, patient, or care team.

I hereby release and hold harmless Dr. Kacie LaChapelle and all members of my care team from any loss of data or information that may be due to technical failures associated with the telehealth/telemedicine service.

The health information that I provide at the time of my telehealth/telemedicine service may be the only source of health information used by the medical professionals during the course of my evaluation and treatment at the time of my telehealth/telemedicine visit, and that such professionals may not have access to my full medical record or information. I understand that I will be given information about test(s), treatments(s) and procedures(s), as applicable, including the benefits, risks, possible problems or complications, and alternate choices for my care through the telehealth/telemedicine visit.

A variety of alternative methods of health care may be available to me, and that I may choose one or more of these at any time. My provider has explained the alternatives to my satisfaction.

If I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms, or experiencing a mental health crisis that cannot be resolved remotely, it may be determined that telehealth/telemedicine services are not appropriate and that a higher level of care is required.

I may anticipate benefits from the use of telehealth/telemedicine in my care, but that no results can be guaranteed or assured.


I hereby consent to the use of telehealth/telemedicine in the provision of care, under the terms and conditions set forth above.

By signing below, I certify that I am the patient and am 18 years of age or older, or that I am the legal representative of the patient, or that I am otherwise legally authorized to provide consent. I have carefully read and understand the above statements. I have had all of my questions answered. I understand that this informed consent will become a part of my medical record.