INFORMED CONSENT FOR TELEPSYCHIATRY

Telepsychiatry is the delivery of psychiatric services using interactive audio and visual electronic systems between a provider and a patient that are not in the same physical location. These services may also include appointment scheduling, communication via email or electronic chat, electronic scheduling, electronic prescribing, and the distribution of patient education materials and forms. In order to receive telepsychiatry services from GHHP, you must be a resident of the State of Texas. It is your responsibility to ensure that you are located in Texas at the time of your appointment, GHHP will not be liable for any issues arising from your location at the time of appointment. Your medications will only be sent within the state of Texas.

The potential benefits of telepsychiatry are:

- Reduced wait time to receive psychiatric care.
- Avoiding the need to travel to a psychiatrist.

The potential risks of telepsychiatry include, but are not limited to:
- A telepsychiatry session will not be exactly the same and may not be as complete as face-to-face service.
- There could be some technical problems (video quality, internet connection) that may affect the telepsychiatry session and affect the decision-making capability of the provider.
- The provider may not be able to provide medical treatment using interactive electronic equipment nor provide for or arrange for emergency care if needed.
- The provider may not be able to perform certain physical exam parameters or check vital signs (weight, blood pressure) as in a face-to-face session.
- A lack of access to all the information that might be available in a face-to-face session, but not in a telepsychiatry session, may result in errors in judgment.
- Delays in medical evaluation and treatment may occur due to deficiencies or failures of the equipment.
- GHHP utilizes software that meets the recommended standards to protect the privacy and security of the telepsychiatry sessions. However, the service cannot guarantee total protection against hacking or tapping into the telepsychiatry session by outsiders.

Alternatives to the use of telepsychiatry: Traditional face-to-face sessions will be provided only when the COVID-19 situation is better.

Patient’s responsibilities


- I will not record any telepsychiatry sessions without written consent from my provider. I understand that my provider will not record any of our telepsychiatry sessions without my written consent.
- I will inform my provider if any other person can hear or see any part of our session before the session begins. The provider will inform me if any other person can hear or see any part of our session before the session begins.
- I understand that it is my responsibility to ensure the proper functioning of all electronic equipment before my session begins. Any cancellation resulting due to issues arising from technology failure on part patient, will result in late cancellation for the patient. This fee is not covered by the insurance.
- I understand that my psychiatrist determines whether or not the condition being diagnosed and/treated is appropriate for a telepsychiatry encounter.
- I understand that I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment but if this is done while the session is going on, a full clinic fee will be charged to the patient's credit card on file. This fee will not be reimbursed by the insurance due to the patient withdrawing consent in the middle of the session.
- I understand that GHHP has the right to withhold or withdraw from providing telepsychiatry care at any time.









I hereby acknowledge that the Clinic Telemedicine Policies have been made available to me for review. I am aware that the policies for this practice may change from time to time and that the current copy of the policy is always available upon request from the GHHP staff. I understand that the clinic is not responsible for providing me with the updated policy and it is my responsibility to request GHHP staff in writing.




If you are filling this form electronically, then type your name in this field will be equivalent to signing your name on a paper document.
 
I hereby consent to engage in telepsychiatry services with GHHP as part of my psychiatric evaluation and treatment. I have read and understood the information provided regarding telepsychiatry and all my questions have been answered by the GHHP staff member.

DECLARATION & ACKNOWLEDGEMENT OF ALL OFFICE POLICIES

I hereby acknowledge that I have reviewed and agree with all the above policies and consent to all terms and consequences. I understand that I am entitled to receive a copy of this document.

By signing the clinic policies, I agree with all policies and procedures as defined by GHHP, PLLC. Failure to abide by these clinic policies will result in termination of treatment for noncompliance of policies. The terms and consequences of this document have been fully explained to me and I have signed it freely and without inducement. All of my questions have been fully answered by the GHHP staff.

I hereby acknowledge that the Clinic Policies have been made available to me for review. I am aware that the policies for this practice may change from time to time and that the current copy of the policy is always available upon request from the GHHP staff. I understand that the clinic is not responsible for providing me with the updated policy and it is my responsibility to request GHHP staff in writing.

As you are filling this form electronically, typing your name in this field will be equivalent to signing your name on a paper document.