Informed Consent for Telehealth Services

The Pisgah Institute 158 Zillicoa Street Asheville, NC

You are considering telehealth services including medication management and therapy. In order for you to make an informed decision, below is some specific information you will want to consider.

I. Medication Management or Psychotherapy

Will be provided using a mobile internet-based application such as Zoom. We have chosen this medium because it is HIPAA compliant and sufficiently protects secure communications. With this said, no internet application is completely secure. In general, we discourage communications outside of your session except in the case of emergency, medication refills, billing, payment, or scheduling. Should you choose to communicate outside of our session, please use the patient portal or call the office. We will not be responding to text messages or social media.

II. Risks

There are possible risks involved in telehealth services. There is a loss of immediacy as compared to face-to-face treatment and therefore the possibility of miscommunication is increased. Another risk is that we may not be in your area and are not familiar with urgent or emergency services that may be required. As such, you are required to complete with Emergency Services Plan at the end of this document. At any point during your telehealth services, either you or your provider may decide that inperson services would be better for your treatment. If that occurs, we will collaboratively work on making an appropriate referral to a qualified provider in your area. To reduce risk to your privacy, I do not record telehealth services sessions.

III. Confidential Video Conferencing

Just like a professional office, video conferencing needs to be conducted in a private area where your confidentiality can be assured. As such, you need to secure a comfortable and private location where interruptions will be reduced to a minimum.

IV. Technology

Many patients wonder how much they need to know about technology in order to participate in telehealth as well as what equipment is required. It is our understanding that most computers and tablets (such as iPad) made in the past 4 years have sufficient hardware and software to be able to participate in video conferencing. Computers like ChromeBooks are unlikely to be sufficient. Teleconferencing software for Zoom can be downloaded for both PC and Mac free of charge to you. If there are any set up costs for the patient, the patient will incur those costs. Naturally, your computer will either need a built-in camera or you can purchase a plug-in camera. You also need to ensure that your internet band width and speed is sufficient to work for video conferencing. Also, you should use an internet service that is secure, encrypted and password protected. If telehealth services are unable to be provided because of technical difficulties, your provider will work with you to find a provider in your area unless you want to continue face-to-face sessions at TPI. If there is an interruption in service because of technical difficulties, your Clinician will call you on the phone to conclude the session. You will only be charged for the time you are able to videoconference.

V. Billing and Fees

Whereas most private and public insurance carriers pay for telehealth services, some may not. As a result, you will be held responsible for any fees incurred that are not covered. Additionally, if there are any costs associated with set up for the patient, the patient will bare those costs.

By signing this form, I confirm that I have read and understood this form and had the opportunity to ask all of the questions I needed to at the time. I also understand that the laws that protect privacy and confidentiality of medical information also apply to telehealth. I understand that I have the right to withhold or withdraw my consent to the use of telehealth at any time without affecting my right to future care or treatment.

Living Wage Certification Logo

Proud to be Living Wage Certified Employers

Just Economics of Western North Carolina (JE) is a regional, membership organization based in Asheville, NC. Their Mission is to educate, advocate, and organize for a just and sustainable economy that works for all in Western North Carolina. Click Here to learn more