Virtual Therapy Consent Form

  • Informed Consent for Telemedicine / Virtual Therapy with New Passages, Inc.

    I agree, along with my therapist, to use one or more of the following platforms for telehealth / Virtual Therapy:

    1. Audio/Video conferencing through an HIPAA compliant platform.
    2. Telephone, facetime, etc.

    If choosing number 2 above, I understand that the platforms listed there are not a secure connection and therefore are not HIPAA compliant.

    I also understand that my insurance company has currently relaxed the HIPAA restrictions on these types of platforms during the COVID-19 outbreak at the recommendation of the Department of Health and Human Services.

    I also understand that New Passages, Inc. will take all precautions possible to keep my Private Health Information (PHI) confidential if a non HIPAA compliant platform is used.

    I also understand that the relaxation of these restrictions are only during the COVID-19 outbreak and will become void once the social distancing recommendations have been lifted.

    I also understand and agree to the following where applicable:

    • I will use a webcam or smartphone during the session. I will be in a quiet, private space that is free of distractions (including cell phones or other electronic devices) during the session.
    • I will use a secure internet connection and not a public or free WiFi connection.
    • I will provide a back-up plan (such as a phone number to be reached) to restart or reschedule the session in the event of technical problems.
    • New Passages, Inc. has verified with your insurance company that your benefit plan covers telehealth / virtual sessions, but that this does not guarantee payment by my insurance company and any denied claims will be my responsibility.
    • If the client is under the age of 14, a parent or guardian must consent for this type of treatment.