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.