Telehealth/Telemedicine Consent Form

By using this form below, you understand that your submission may not be a secure and confidential form of communication.
If you wish to assure your confidentiality, rather than filling out and submitting this form, you can print and FAX the PDF form you received to: 802-727-4634.
 
Telehealth, or Telemedicine, are both terms that are used sometimes interchangeably to refer to means of connecting (usually electronically, and usually but not always interactively in real time). The mediums include live interactive video (both audio and video), telephone conversations (audio only), text conversations, and email conversations. It's a method of delivering health services when the provider and the recipient are not in the same physical location.
 
1) I hereby authorize David Levingston to use a telehealth practice platform for telecommunication for evaluating, testing, diagnosing, and treating my condition.
 
2) My participation means I consent and authorize the use of telehealth for my treatment.
 
3) When possible, I understand we will use either Google Meet or the Zoom live video platform for sessions. I understand that other platforms (including Skype, FaceTime, and telephone) may not be secure and that the privacy of my PHI (Protected Health Information) might be compromised.
 
4) I understand that technical difficulties may occur before or during the telehealth sessions and that my appointment may not be started or ended as intended.
 
5) In the event that we are unable to establish a video connection, I understand that we will use our phones as a backup. If we get disconnected, David will wait up to 3 minutes for me to call him. If I don’t, I am still responsible for covering the cost of the session.
 
6) If my insurance only covers live interactive video and I am unable to connect due to technical issues on my end, and we are unable to find another time to meet during the same week, I will be responsible for covering the cost at the usual private pay rate for sessions.
 
7) I understand that my current insurance may not cover the additional fees of the telehealth practices and I may be responsible for any fee that my insurance company does not cover.
 
8) I agree that my medical records on telehealth can be kept for further evaluation, analysis and documentation, and in all of these, my information will be kept private according to privacy and confidentiality laws and ethics.
 
9) I understand that in light of the situation with the coronavirus, some of the cost responsibilities might be relaxed.
 
Please fill all fields below to indicate your agreement: