Online Mental Health Evaluation Agreement*
Tele-psychology/tele-medicine is the delivery of services using interactive audio or audiovisual electronic systems where the mental health professional and the patient are not in the same physical location. The interactive electronic systems used in tele-psychology/tele-medicine incorporate network and software security protocols to protect the confidentiality of patient information and audio and visual data. These protocols include measures to safeguard the data and to aid in protecting against intentional or unintentional corruption. However, these electronic systems may not comply with HIPAA, the federal medical privacy law.
Potential benefits include increased accessibility to a mental health professional care and convenience.
I have the right to withhold or withdraw my consent to the use of tele-psychology/tele-medicine at any time. The laws that protect the privacy and confidentiality of medical information also apply to tele-psychology/tele-medicine. I understand that the information disclosed by me during the course of my consultation is generally confidential, except under under certain circumstances where disclosure is required by the law (i.e., where there is a reasonable suspicion of child, dependent, or elder abuse or neglect; and where a client presents a danger to self, to others, to property, or is gravely disabled). The computer technology used by the assigned mental health professional is encrypted to prevent the unauthorized access to my private medical information, but I understand that there are risks and consequences from tele-psychology/tele-medicine, including, but not limited to, the possibility, despite reasonable efforts on the part of the mental health professional, that the transmission of my information could be disrupted or distorted by technical failures; the transmission of my information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons. I understand that tele-psychology/tele-medicine services may not be as complete as face-to-face services. If the mental health professional believes that I would be better served by another Medical Or Mental Health Professional, I will be advised and referred to an appropriate Medical or Mental Health Professional who can provide such services in my area.I understand that while email may be used to communicate with the mental health professional, confidentiality of emails cannot be guaranteed. I understand that I have a right to access my medical information and copies of medical records in accordance with HIPAA privacy rules and applicable state law.
I understand that I am responsible for (1) providing the necessary computer, telecommunications equipment and internet access for my tele-psychology/tele-medicine sessions; (2) securing information on my computer; and (3) arranging a location with sufficient lighting and privacy that is free from distractions or intrusions for my tele-psychology/tele-medicine session.
Patient Consent To The Use of tele-psychology/tele-medicine
I have read and understand the information provided above regarding tele-psychology/tele-medicine, I hereby give my informed consent for the use of tele-psychology/tele-medicine in my care. All evaluations are subject to denial, and denial of an Emotional Support Animal will not result in a refund for the evaluation. I recognize and accept all risks and limitations involved in seeking remote treatment therapies by my assigned licensed Mental Health Professional, and hold United Service Dog, LLC, its agents, and network of licensed Mental Health Professionals harmless from the results, diagnoses, and recommendations from of my Emotional Support Animal evaluation.
Release of Information
This release of information authorizes information from my records and this evaluation to be shared between my assigned licensed Mental Health Professional and the agents of United Service Dog, LLC. I give permission to my assigned licensed Mental Health Professional permission to release this information to United Service Dog, LLC and its agents for the purpose of delivery, payment processing, and completion of my Online Evaluation. I understand that this authorization is valid for exactly one year from the day this agreement has been signed. I also understand that my evaluation and records may not be released to any other organization without my written permission and consent. My assigned licensed Mental Health Professional is released from all liability that may arise from the information exchanged to United Service Dog, LLC and its agents.