Consent for Telehealth Services

Services Provided

I understand that mental health (MH) and psychiatric services may be provided through two-way interactive video communications and/or electronic transmission of information, known as "telehealth" or "telemedicine." This means that I will receive evaluation and treatment from a provider located remotely. Given the unique nature of telehealth, I agree to the following terms:

1. The provider will be located at a different site than me. I will connect to remote services from either the clinic or another private and comfortable location within the State of Minnesota (MN).
2. I will identify and sign a release of information (ROI) form for an emergency contact (EC) who will be available in close physical proximity during all telehealth sessions in case of an emergency. I will provide my provider with the contact information for this person.
3. I will be informed if any additional staff, such as a trainee, will be present during the session and will have the option to decline.
4. Video recordings of the telehealth session may be taken with my written permission. These recordings may be retained, viewed, and used for teaching, training, technical assistance, or administrative purposes.
5. In case of technical issues, I can directly contact my provider. They will assist me in resolving the problems or transfer me to appropriate support.

I understand that my participation in this process is voluntary and involves a waiver of the usual right to provider-client privacy. I also acknowledge that there may be unintentional risks of disclosing my personal data.

Refusal

I understand that I have the right to refuse or discontinue participation in the telehealth session at any time. Additionally, I can request that my information not be transmitted if I make a written request before transmission occurs.

Acknowledgement and Attestation

I confirm that the provider(s) involved in my care have adequately explained the telehealth sessions, and all my questions have been addressed satisfactorily. Understanding the above, I consent to the telehealth process described.

Client