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:
- Audio/Video conferencing through an HIPAA compliant platform.
- 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.
