State and federal law requires that you sign an informed consent for the receipt of teletherapy services. This agreement contains information about teletherapy before we can engage in use of this alternative service delivery modality.
CONSENT FOR TELEHEALTH CONSULTATION
I understand that my speech- language pathologist wishes me to engage in a telehealth consultation.
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My speech-language pathologist explained to me how the video conferencing technology that will be used to affect such a consultation will work during therapy sessions.
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I understand that a telehealth consultation has potential benefits including easier access to care and the convenience of meeting from a location of my choosing.
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I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.
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I have had a direct conversation with my provider, during which I had the opportunity to ask questions in regard to this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.
CONSENT TO USE THE TELEHEALTH BY CommuniKate, PLLC
Zoom Video Conferencing is the technology service we will use to conduct telehealth videoconferencing appointments. It is simple to use and I was provided with a password to sign in. By signing this document, I acknowledge:
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CommuniKate, PLLC is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911.
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Though my provider and I may be in direct, virtual contact through the Telehealth Service, neither CommuniKate, PLLC or Katherine Lamin provides any medical or healthcare services or advice including, but not limited to, emergency or urgent medical services.
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The CommuniKate, PLLC Service facilitates videoconferencing and is not responsible for the delivery of any healthcare, medical advice or care.
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I do not assume that my provider has access to any or all of the technical information in the CommuniKate, PLLC Service – or that such information is current, accurate or up-to-date. I will not rely on my health care provider to have any of this information in the CommuniKate, PLLC Service.
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To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment.
By signing this form, I certify:
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That I have read or had this form read and/or had this form explained to me
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That I fully understand its contents including the risks and benefits of the procedure(s).
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That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.
