ACESO BEHAVIORAL HEALTH
VERBAL CONSENT TO PARTICIPATE IN A TELEMEDICINE CONSULTATION/TREATMENT
Note: Please read information about your upcoming telemedicine / telehealth / tele-psychiatry visit. You will be asked by your provider if you agree with this document and understand it. You can ask your provider any questions you may have.
- I authorize and voluntarily consent to the participation and treatment of myself in a Telemedicine Consultation and/or treatment with ACESO Behavioral Health (“ACESO”).
- I understand that as a participating patient, my physician and I will communicate by audio/video conferencing with physicians, mental health providers, and health care professionals at ACESO. I understand that medicine is not an exact science and there are no guarantees that can be made regarding outcomes and results of these examinations and treatments.
- It has been explained to me how the audio/video conferencing technology will be used to conduct a visit. I understand that this visit will not be the same as an in-person visit due to the fact that I will not be in the same room as the healthcare provider at the distant site. I also understand that I have the option to see a provider in person, if I chose.
- I further understand that there are potential risks to telemedicine, including but not limited to, interruptions, unauthorized access, and technical difficulties. I understand that either the healthcare provider or I can discontinue my child’s telemedicine health visit if it is felt that the videoconferencing connections are not adequate for the situation.
- I understand it may be necessary and useful for others to be present during the visit other than my healthcare team and provider in order to operate the a/v equipment. These individuals are bound to maintain confidentiality of all information obtained.
- During my telemedicine visit, I understand that the responsibility of the telemedicine healthcare provider concludes upon the termination of the a/v conference connection and ACESO is not responsible for the actions of the distant site.
- By signing this consent, I authorize my physician to release any relevant medical information, pertaining to my medical condition and medical care to ACESO, its physicians, mental health providers, and healthcare professionals. I also authorize ACESO, or its providers, to release any and all information to my insurance company or any other agent that may be responsible for paying my medical bills.
- I understand that I have the right to withdraw my consent at any time. If at any time I am not satisfied with the services rendered.
- I have read (or have had read to me) this document carefully, and hereby consent to participate in the Telemedicine consultation/services under the terms described above.
