Specific Telehealth Informed Consent and Informed Consent for Mental Health and Medication Management Services
IMPORTANT NOTICE: DO NOT USE THESE SERVICES FOR EMERGENCY MEDICAL OR MENTAL HEALTH NEEDS. IF YOU ARE EXPERIENCING A MEDICAL OR MENTAL HEALTH EMERGENCY, YOU SHOULD DIAL “911” IMMEDIATELY AND/OR GO TO THE NEAREST EMERGENCY ROOM.
Telehealth is the use of two-way secure audio-visual electronic communications, information technology, or other means to enable a healthcare provider and a patient at different locations to communicate and share individual patient health information for the purpose of rendering or receiving clinical health care services. This “Telehealth Informed Consent” informs the patient (“I”, “patient,” “you,” or “your”) concerning the treatment methods, risks, and limitations of using a telehealth platform.
1. Services Provided.
Cerebral Inc. (“Cerebral Inc.”) provides certain non-clinical administrative and financial support services and licenses technology to Cerebral Medical Group, P.A., its affiliated medical practices (each a “Medical Group” and collectively the “Medical Groups”), and their engaged healthcare providers (“Providers”). The Medical Groups and Providers use Cerebral Inc.’s technology platform to assist them in providing their patients various healthcare services, all of which are done via telehealth and some of which may include writing medically necessary prescriptions. Cerebral Inc. does not diagnose or treat any medical condition, provide any healthcare service, or control or interfere with any medical or clinical decision made by a Provider. Cerebral Inc. does not own or operate any of the Medical Groups, nor does it employ, engage or supervise any Provider, each of whom are solely responsible for all healthcare decisions.
The telehealth services offered by the Medical Groups and Providers may include a patient consultation, assessment, diagnosis, treatment recommendation, education, care management, prescription, and/or a referral to in-person care, as determined clinically appropriate by the Provider (the “Services”). Depending on your state laws, Providers may include physicians, physician assistants, nurse practitioners, registered professional nurses, psychiatrists, psychologists, psychiatric nurse practitioners, mental health counselors, professional counselors, therapists, therapy associates, clinical counselors, care counselors, clinical social workers, and other care providers.
2. Electronic Transmissions.
The types of electronic transmissions that may occur using the telehealth platform include, but are not limited to:
3. Expected Benefits.
Benefits you may expect to receive from using telehealth services may include, but are not limited to:
4. Service Limitations.
PROVIDERS DO NOT ADDRESS MEDICAL EMERGENCIES. IF YOU BELIEVE YOU ARE EXPERIENCING A MEDICAL EMERGENCY, YOU SHOULD DIAL 9-1-1 AND/OR GO TO THE NEAREST EMERGENCY ROOM IMMEDIATELY. IF YOU ARE THINKING ABOUT SUICIDE OR IF YOU ARE CONSIDERING TAKING ACTIONS THAT MAY CAUSE HARM TO YOURSELF OR OTHERS, CALL THE NATIONAL SUICIDE PREVENTION HOTLINE ANYTIME AT 9-8-8 OR GO TO THE NEAREST EMERGENCY ROOM. YOU CAN ALSO USE THE 24/7 CRISIS TEXT LINE BY TEXTING “HOME” TO 741-741. PLEASE DO NOT ATTEMPT TO CONTACT CEREBRAL INC., ANY MEDICAL GROUP, OR YOUR PROVIDER. AFTER RECEIVING EMERGENCY HEALTHCARE TREATMENT, YOU SHOULD VISIT YOUR LOCAL PRIMARY CARE PROVIDER.
The primary difference between telehealth and direct in-person service delivery is the inability to have direct, physical contact. Accordingly, some clinical needs may not be appropriate for a telehealth visit and your Provider, exercising their professional medical judgment, will make that determination.
Providers are an addition to, and not a replacement for, your local primary care provider. Responsibility for your overall medical care should remain with your local primary care provider if you have one, and we strongly encourage you to locate one if you do not.
The Medical Groups do not have any in-person clinic locations.
5. Security Measures.
The electronic communication systems will incorporate network and software security protocols to protect the confidentiality of your patient identification and health and imaging information and will include commercially reasonable measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption. All the services delivered to you through telehealth will be delivered over a secure connection that complies with the requirements of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”).
6. Possible Risks.
7. Your Rights Regarding Telehealth.
You have the right to:
8. Specific Informed Consent for Telehealth.
By signing below, you acknowledge that you understand and agree with the following:
9. Additional State-Specific Consents:
The following consents apply to patients accessing the Services for the purposes of participating in a telehealth consultation as required by the states listed below:
Alaska. You understand that your primary care provider may obtain a copy of your records of your telehealth encounter.
This document is intended to provide you with all of the information is required by the Board of Professional Counselors which regulates all licensed professional counselors. You may contact the Board with any questions or concerns.
Arizona. You are entitled to all existing confidentiality protections, including where a provider may only disclose all or part of your medical record and payment record as authorized by state or federal law or written authorization signed by you or your health care decision maker, pursuant to A.R.S. § 12-2292. You also understand all medical reports resulting from the telemedicine consultation are part of your medical record as defined in A.R.S. § 12-2291. You also understand dissemination of any images or information identifiable to you for research or educational purposes shall not occur without your consent, unless authorized by state or federal law. (Ariz. Rev. Stat. Ann. § 36-3602(D)).
Colorado. If you have a concern or complaint about the mental health professionals providing care to you, you may contact a board agency to assist you. You are entitled to the consent requirements outlined under 2 CO ADC 502-1:21.170.4. The confidentiality of your individual records, including all medical, mental health, substance use, psychological, and demographic information shall be protected with the applicable state and federal laws and regulations, as provided under 2 CO ADC 502-1:21.170.2.
Connecticut. You understand that each telehealth provider shall, at the time of the initial telehealth interaction, ask the patient whether the patient consents to that provider’s disclosure of records concerning the telehealth interaction to your primary care provider. You further understand that your primary care provider may obtain a copy of your records of your telehealth encounter, upon your consent. (Conn. Gen. Stat. Ann. § 19a-906(d)).
District of Columbia. You have been informed of alternate forms of communication between you and a physician for urgent matters. (D.C. Mun. Regs. tit. 17, § 4618.10). Relevant communications with the physician, including those done via electronic methods shall be documented and filed in your medical record. (D.C. Mun. Regs. tit. 17, § 4618.9).
Georgia. You have been given clear, appropriate, accurate instructions on follow-up in the event of needed emergent care related to the treatment. (Ga. Comp. R. & Regs. 360-3-.07(a)(7)).
Idaho. If you want to register a formal complaint about a provider, you should visit the Idaho Board of Medicine’s website: https://elitepublic.bom.idaho.gov/IBOMPortal/Home.aspx.
Illinois. If you need to register a formal complaint about a professional regulated under the Illinois Division of Professional Regulation, you may file a formal complaint here: https://www.idfpr.com/admin/DPR/DPRcomplaint.asp
Indiana. If you want to register a formal complaint about a provider, you should visit the Office of the Indiana Attorney General Consumer Protection Division’s website, here: https://www.in.gov/attorneygeneral/consumer-protection-division/consumer-complaint/
Iowa. If you want to register a formal complaint about a provider, you should visit the Iowa Board of Medicine’s website here: https://medicalboard.iowa.gov/consumers/filing-complaint
Kansas. You understand that if you have a primary care or other behavioral health treating provider and if you consent to us sharing your information with such provider, then we are obligated to send within three business days a report to such primary care or other treating physician of the treatment and services rendered by the Medical Groups during the telemedicine encounter. (Kan. Stat. Ann. § 40-2,212(2)(d)(2)(A)). The process for filing a complaint may be found here:http://www.ksbha.org/complaints.shtml
Kentucky. If you want to register a formal complaint about a provider, you should visit the Kentucky Board of Medicine’s website, here: https://kbml.ky.gov/grievances/Pages/default.aspx
Louisiana. You understand the role of other health care providers that may be present during the consultation, other than the Medical Group provider. (46 La. Admin. Code Pt XLV, § 7511).
Maine. If you want to register a formal complaint about a provider, you should visit the Maine Board of Licensure in Medicine’s website, here: https://www.maine.gov/md/complaint/file-complaint
Maryland. The knowledge, experiences, and qualifications of the consultant providing data and information to the provider of the telehealth services need not be completely known to and understood by the provider. The quality of transmitted data may affect the quality of services provided by the provider. Changes in the environment and test conditions could be impossible to make during delivery of telehealth services. Telehealth services may not be provided by correspondence only. (Md. Code Regs. 10.41.06.04). If you want to register a formal complaint about a physician, you should visit the medical board’s website, here: https://www.mbp.state.md.us/resource_information/faqs/resource_faqs_complaints.aspx
Nebraska. If you are a Medicaid recipient, you retain the option to refuse the telehealth consultation at any time without affecting your right to future care or treatment and without risking the loss or withdrawal of any program benefits to which the patient would otherwise be entitled. All existing confidentiality protections shall apply to the telehealth consultation. You shall have access to all medical information resulting from the telehealth consultation as provided by law for access to my medical records.
Dissemination of any patient identifiable images or information from the telehealth consultation to researchers or other entities shall not occur without your written consent. You understand that you have the right to request an in-person consult immediately after the telehealth consult and you will be informed if such consult is not available. (Neb. Rev. Stat. Ann. § 71-8505; 471 Neb. Admin. Code § 1-006.05).
New Hampshire. You understand that the provider may forward your medical records to your primary care or treating provider. (N.H. Rev. Stat. § 329:1-d).
New Jersey. You understand that you have the right to request a copy of your medical information and you understand your medical information may be forwarded directly to your primary care provider or health care provider of record, or upon your request, to other health care providers. (N.J. Rev. Stat. Ann. § 45:1-62).
Oklahoma. If you want to register a formal complaint about a provider, you should visit the Oklahoma Board of Medical Licensure and Supervision’s website here: https://www.okmedicalboard.org/complaint
Or, the Oklahoma Board of Osteopathic Examiners’ website, here: https://www.ok.gov/osboe/
Oregon. If you have a concern or complaint about the mental health professionals providing care to you, you may contact a board agency to assist you. You understand that the provider may ask if you need more detail. ORS 17-52-677.07
Pennsylvania. If you have a concern or complaint about the mental health professionals providing care to you, you may contact a board agency to assist you. You also understand that you may be asked to confirm your consent to behavioral health or telepsychiatry services. 40 PS §1303.504(b).
South Carolina. The information you share in psychotherapy is protected health information and is generally considered confidential by both South Carolina state law and federal regulations, with some limited exceptions (e.g., may be shared with another healthcare provider, required by subpoena). Your mental health practitioner is also mandated by standards - through Duties to Warn - to breach confidentiality if: (1) you are threatening self-harm or suicide; (2) you are threatening to harm another or homicide; (3) a child has been or is being abused or neglected; and/or (4) a vulnerable adult has been or is being abused or neglected.
You also understand that if you are a Medicaid beneficiary, you can withdraw your consent at any time.
Tennessee. You understand that you may request an in-person assessment before receiving a telehealth assessment if you are a telehealth recipient.
The information you share in psychotherapy is protected health information and is generally considered confidential by both Tennessee state law and federal regulations, with some limited exceptions (e.g., may be shared with another healthcare provider, required by subpoena). Your mental health provider may also disclose information without consent: (1) if disclosure is necessary for other duties that the mental health provider is bound by, (2) if it is necessary to assure service or care is the least drastic means, (3) due to a court order, (4) if it is solely information to a residential service recipient, (5) to facilitate continuity of service to another health care provider, (6) if a custodial agent for another stat agency that has legal custody of the service cannot perform the agent’s duties, or (7) it is necessary for the preparation of a post-mortem examination. Tenn. Code Ann. §33-3-105.
Texas. You have been informed of the following notice:
NOTICE CONCERNING COMPLAINTS -Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, acupuncturists, and surgical assistants, may be reported for investigation at the following address: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Assistance in filing a complaint is available by calling the following telephone number: 1-800-201-9353, For more information, please visit our website at www.tmb.state.tx.us.
AVISO SOBRE LAS QUEJAS- Las quejas sobre médicos, asi como sobre otros profesionales acreditados e inscritos del Consejo Médico de Tejas, incluyendo asistentes de médicos, practicantes de acupuntura y asistentes de cirugia, se pueden presentar en la siguiente dirección para ser investigadas: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Si necesita ayuda para presentar una queja, llame al: 1-800-201-9353, Para obtener más información, visite nuestro sitio web en www.tmb.state.tx.us
Utah. You understand (i) the fees that may be charged to you for the telehealth service; (ii) to whom your health information may be disclosed and for what purpose, and have received information on any consent governing release of my patient-identifiable information to a third-party; (iii) your rights with respect to patient health information; (iv) appropriate uses and limitations of the site, including emergency health situations. You were warned of: potential risks to privacy notwithstanding the security measures and that information may be lost due to technical failures, and agree to hold the provider harmless for such loss. You have been provided with the location of the Medical Groups’ website and contact information. You understand that you are able to select a provider of your choice, to the extent possible. You are able to select a pharmacy of choice. You are able to a (i) access, supplement, and amend your patient-provided personal health information; (ii) contact your provider for subsequent care; (iii) obtain upon request an electronic or hard copy of my medical record documenting the telemedicine services, including the informed consent provided; and (iv) request a transfer to another provider of my medical record documenting the telemedicine services. (Utah Admin. Code r. 156-1-602).
Vermont. You have been informed that if you want to register a formal complaint about a provider, you should visit the Vermont Board of Medical Practice’s website, here: https://www.healthvermont.gov/health-professionals-systems/board-medical-practice/file-complaint
Or, the Vermont Board of Osteopathic Examiners’ website, here: https://sos.vermont.gov/opr/complaints-conduct-discipline/
Washington. You understand the purposes of and resources available to you surrounding this treatment, including the right to refuse treatment, and your responsibility in choosing a provider and treatment that best suits your needs. RCW 18.19.060.
The information you share in psychotherapy is protected health information and is generally considered confidential by both Washington state law and federal regulations, with some limited exceptions (e.g., may be shared with another healthcare provider, required by subpoena). RCW 18.19.180.
Counselors practicing counseling for a fee must be credentialed with the department of health for the protection of the public health and safety. Credentialing of an individual with the department of health does not include a recognition of any practice standards, nor necessarily imply the effectiveness of any treatment. The purpose of the Counselor Credentialing Act, chapter 18.19 RCW, is to: (A) Provide protection for public health and safety; and (B) Empower the citizens of the state of Washington by providing a complaint process against those counselors who would commit acts of unprofessional conduct. Clients have the right to choose counselors who best suit their needs and purposes.
A copy of the acts of unprofessional conduct in RCW 18.130.180 can be found on the Washington State Legislature’s website at this address http://apps.leg.wa.gov/RCW/default.aspx?cite=18.130.180.
10. Specific Informed Consent for Mental Health and Medication Management Services.
This “Specific Informed Consent for Mental Health and Medication Management Services” informs you of the treatment methods, risks, and limitations of accessing mental health and/or medication management services.
By signing below, you acknowledge that you understand and agree with the following:
Therapy, Counseling and Coaching
Therapy, counseling, and coaching can be helpful to individuals experiencing mental health challenges. Benefits can include improved mood, improved relationships, and resolution of specific issues. Therapy, counseling and/or coaching can often lead to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, and increased skills for managing stress. Like all forms of treatment, therapy, counseling or coaching is not guaranteed to work for everybody. These treatments require your active and honest participation during the sessions and you working on things outside of your sessions. You and your Provider may need to explore unpleasant aspects of your life which may, at times, lead to feelings of distress (e.g., guilt, anxiety, frustration, etc.). These unpleasant aspects are generally temporary but are important to discuss when present. Thus, it is important to let your Provider know if you feel that your goals aren’t being met. These issues can be addressed in sessions, the length of which vary depending on your clinical needs. Occasionally Providers need to discontinue therapy, counseling or coaching. Although this is rare, if your treatment ends prematurely, a suitable referral or transition will be discussed with you.
Your Provider, exercising their independent professional medical judgment, might determine that medications may be indicated, which may occur prior to initiating therapy or when your symptoms are not responsive to therapy alone. When a mental illness markedly impacts your ability to work, maintain interpersonal relationships, or properly care for your basic needs, medication may offer much needed relief. Not everyone is a good candidate for medication therapy. Such therapy requires adherence to dosage, frequency, and follow-up. Before deciding to start medication, your Provider will consider your ability to adhere to medication treatment. Additionally, your physician will discuss the risks, benefits, side effects, government warnings, and alternative treatments (which always includes not using medications) with you.
Consent for Treatment
This consent provides the Medical Groups and Providers with your permission to perform reasonable and necessary mental health examinations, testing, treatment, case management, medication management, and other appropriate healthcare services as determined by your Provider. By signing below, you are agreeing that (1) you intend that this consent is continuing in nature even after a specific diagnosis and treatment recommendation, (2) you consent to treatment by any Provider you choose, (3) the consent will remain in effect until it is revoked in writing, and (4) you have the right to discuss your diagnosis and treatment with your Provider (including the purpose and potential risks and benefits).
Consent to Enroll In Automatic Medication Refill Program
By signing this Informed Consent for Mental Health and Medication Management Services, I am requesting and authorizing my selected pharmacy, which may include CerebralRx, to refill all future Provider-authorized refills for any particular refill, for the number of times authorized or for the period authorized, without my request for a refill and, if home delivery is available and requested, deliver the medication(s) to my home address (the “Automatic Refill Program”). I acknowledge that I have the right to rescind or revoke my authorization to enroll in the Automatic Refill Program at any time by notifying my selected pharmacy or my Provider of such rescission or revocation.
By giving my signature or clicking the "I Consent" button below, I hereby confirm and attest that I have carefully read and understand the terms and conditions above, and I agree to this Telehealth Informed Consent and this Informed Consent for Mental Health and Medication Management Services, and to utilize telehealth services in the provision of care. I certify that I am the patient and am 18 years of age or older, or the legal representative of the patient, or otherwise legally authorized to consent. I understand that this informed consent will become a part of my medical record.
Signature of Patient or Patient’s Legal Representative Date
Relationship to Patient (if Patient’s Legal Representative)