Telehealth Information - Community Health Center of NRV

TeleVisit Appointment Consent Form

I understand that a TeleVisit appointment involves the use of electronic devices such as a computer, tablet, smart phone or telephone to enable two-way communication between the patient and their provider at different locations for the purpose of diagnosis, treatment, therapy, follow-up and /or education.

Transmitted information may include any of the following:

• Patient medical records
• Live two-way audio and video
• Patient materials such as prescriptions, test orders, and patient education
• Pictures from the patient to the provider

I consent for my medical, dental, and/or behavioral health provider at the Community Health Center of the New River Valley to conduct a health care appointment with me through a TeleVisit appointment.
I understand that the laws that protect privacy and the confidentiality of my medical information also apply to TeleVisits.

I understand that my insurance carrier will have access to my medical records for quality review/audit as they would with an in-person office visit.

I understand that I will be responsible for any copayments, deductibles or coinsurances that apply to my TeleVisit appointment.

I understand that I have the right to withhold or withdraw my consent for the use of TeleVisits during my care at any time, without affecting my right to future in-person care or treatment.

I may revoke my TeleVisit consent in writing at any time by contacting:

Community Health Center of the New River Valley
Ashley Slagel-Perry, Privacy Officer
215 Roanoke St.
Christiansburg, VA 24073
540-381-0820

This consent is valid for one year from the date the consent was signed and dated and my provider at the Community Health Center of the New River Valley may provide health care services to me via TeleVisit without the need for me to sign another consent form.

Patient or Responsible Party Name

Relationship

Date of Birth

Patient or Responsible Party Signature

Date

Website

I hereby consent to engaging in Behavioral Health Telemedicine and/or In Office visits in an office with a licensed Behavioral Health Provider or Supervisee in Social Work through the Community Health Center of the New River Valley. I understand that my participation is completely voluntary, and I may terminate the therapeutic relationship at any time. If I am out of services for 30 days without consulting with my therapist, it will be assumed that I am no longer interested in services and I will be considered terminated from the behavioral health program.

Confidentiality: I understand that all information regarding services is confidential and will not be released to any other agency or individual without my knowledge and consent, except when required by law. I understand that the Center and my therapist are required to report knowledge of abuse and/or neglect of a person who is presently a minor, elderly or disabled. I also understand that the Center and my therapist may break confidentiality if there is a serious intent to harm myself or others. I further understand that my therapist may consult with other organizations, mental health professionals or medical care providers to provide the best services possible for me. I understand that my therapist will provide the minimum necessary clinical information to my insurance provider and/or managed care organization to both protect my confidentiality and authorize services as needed. I understand that if I see a therapist that is a “Supervisee In Social Work”, that my information will be shared with their clinical supervisor(s), Ally Yeatts or Erin Shaffer. I understand that I can contact Ally Yeatts or Erin Shaffer with any concerns or questions related to my care by calling the Christiansburg Center at (540) 381-0820.

Telemedicine:I understand that Behavioral Health Telemedicine includes the practice of health care delivery, diagnosis, consultation, treatment, transfer of mental health data, and education using interactive audio, video, or data communications. I understand that the recording or dissemination of any personally identifiable images or information from the Behavioral Health Telemedicine interaction shall not occur without my written consent.

I understand that there are risks and consequences from Behavioral Health Telemedicine, including, but not limited to, the possibility, despite reasonable efforts on the part of my therapist, that: the transmission of my medical or mental health information could be disrupted or distorted by technical failures; the transmission of my medical or mental health information could be interrupted by unauthorized persons; the electronic storage of my medical information could be accessed by unauthorized persons; and/or limited ability to respond to emergencies.

If the telemedicine call becomes disconnected, your provider will attempt to contact you via phone. If needed, your provider may leave you a detailed voice message at the number provided during the session.

In addition, I understand that Behavioral Health Telemedicine-based services and care may not be as complete as face-to-face services.

No Show/Cancellation Policy: I understand that I need to call to cancel or reschedule any appointments within 24 hours of my appointment time. The Center allows for 3 No Shows within a calendar year. If I have 3 no shows for appointments within the Center, which includes same day cancellations or rescheduled appointments, I will be required to meet with the Director of Behavioral Health Integration prior to being able to schedule any follow up appointments. If I continue to No Show or have late cancellations/reschedules after this meeting, I may be discharged from the practice. I understand that it is important to arrive on time for my appointments with my Behavioral Health Provider to ensure I receive full benefit from counseling. If I arrive to my appointment more than 10 minutes late, I may be asked to reschedule my appointment.

Legal Fees: I understand that if I am involved in or anticipate being involved in legal or court proceedings, I will let my therapist know as soon as possible. In situations requiring court involvement, I understand that the fee is $500 per half day and $1,000 per day for court appearances. In addition, $150 per hour will be charged per hour spent for preparation for court testimony including, but not limited to, consulting with attorneys, reviewing the file and report/letter writing. In the event of a settlement or cancellation of the trial/hearing with less than 24 hours’ notice, a charge will be levied for those hours originally set aside for the trial/hearing. These services are not reimbursable by medical insurance. I understand that if I need to talk with the Center staff when the office is closed, I may call and leave a message on the voice mail or send a message through the patient portal. I understand that my therapist may not be able to respond immediately. I should use the patient portal for routine scheduling or to request a call from my therapist. Patient portal should not be utilized for urgent or emergent matters. If I have an emergency, I understand that I should contact ACCESS, 911 or go the nearest hospital emergency department.

In Case of Emergency During Telemedicine Appointments:

My Location/Home Address:

Phone

Emergency contact

First

Last

Preferred Method of Contact:

I understand that my emergency contact and/or appropriate authorities may be contacted in the case of emergency.

Name *

First

Last

Signature *

Date *

Behavioral Health Provider Name

First

Last

Behavioral Health Provider Signature

Date

I understand that my emergency contact and/or appropriate authorities may be contacted in the case of emergency.

Consent to Disclose of Part 2 Records

Name *

First

Middle

Last

SSN *

Date of birth *

I ____ authorize the Center’s Part 2 program(s) to disclose my behavioral health/substance use disorder records as follows: *

Please type the patient’s full name in box.

To the Center for purposes of treatment, care coordination, payment, and health care operations: *

All my behavioral health/substance use disorder records

To the following pharmacies for purposes of treatment: *

My behavioral health/substance use disorder records

Pharmacy name *

Pharmacy phone number

To the following providers outside of the Center (i.e., therapists or medical providers) for purposes of treatment and care coordination: *

All my behavioral health/substance use disorder records
The following parts of my behavioral health/substance use disorder records
None of my behavioral health/substance use disorder records

For additional purposes (if applicable): To authorize The Center’s Part 2 Program to disclose substance use disorder records to additional individuals and/or entities (such as to family members or to additional treatment providers) please complete this section:

Outside provider (if selected)

Insurance providers, such as Anthem, Blue Cross or Aetna, for the purpose(s) (e.g., treatment, payment, personal reasons): *

Bill my insurance provider
I have insurance but elect to self pay
I do not have insurance

Signature of Patient or Legal Representative *

Date *

This consent form will expire 1 Year from the date it is signed.

If Signed by Legal Representative, Relationship to Patient

I understand that I may revoke this authorization at any time provided that any such revocation is in writing and submitted to Ashley Slagel-Perry at Community Health Center of the New River Valley, 215 Roanoke St., Christiansburg, VA 24073, 540-381-0820, slagelperry@chcnrv.org except to the extent that action has been taken in reliance on it. Acting in reliance includes the provision of treatment services in reliance on a valid consent to disclose information to a third-party payer.

I understand the conditions of my treatment may be modified up to and including denial of services should I refuse to consent to the disclosure of my substance use disorder records, as permitted by state law.