TelehealthInformedConsent

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:

  • Appointment scheduling;
  • Completion, exchange, and review of medical intake forms and other clinically relevant information (for example: health records; images; output data from medical devices; sound and video files; diagnostic and/or lab test results) between you and your Provider via asynchronous and/or synchronous communications;
  • Two-way interactive audio in combination with store-and-forward communications; and/or two-way interactive audio and video interaction;
  • Treatment recommendations by your Provider based upon their review and exchange of clinical information;
  • Delivery of a consultation report with a diagnosis, treatment, and/or prescription recommendations, as your Provider deems clinically appropriate;
  • Prescription refill reminders (if applicable); and/or
  • Other electronic transmissions for the purpose of rendering clinical care to you.

3. Expected Benefits.

Benefits you may expect to receive from using telehealth services may include, but are not limited to: 

  • Improved access to care and greater convenience by enabling you to remain in your preferred location while your Provider consults with you;
  • Lower cost;
  • Improved Provider-patient engagement;
  • Additional privacy with no public waiting rooms or receptionists calling out your name;
  • Convenient access to follow-up care. If you need to receive non-emergency follow-up care related to your treatment, please contact your Provider by sending a message through the platform portal; and/or
  • More efficient care evaluation and management. 

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.

  • Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment and technologies, or Provider availability.
  • In the event of an inability to communicate as a result of a technological or equipment failure, please contact us at 415-403-2156 or support@cerebral.com.
  • In rare events, your Provider may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled telehealth consult or an in-person meeting with your local primary care doctor.
  • While the Medical Groups and Providers are HIPAA-complaint, in  very rare events, security protocols could fail, causing a breach of privacy of personal medical information.
  • During the initial screening, your Provider may determine that you should be seen in person, either by your primary care provider or in a recommended facility.
  • Your telehealth visit may not be covered by your medical insurance, in which case you may elect to pay out-of-pocket (via credit or debit card) or change or cancel your subscription plan.
  • You may not be matched with a Provider that meets any or all of your preferences or requirements.
  • Your Provider may determine in the Provider’s own discretion and professional judgment that medication is not right for you and decide not to prescribe any medication.

7. Your Rights Regarding Telehealth.

You have the right to:

  • Refuse to participate in services delivered via telehealth and be made aware of alternatives and potential drawbacks of participating in a telehealth visit versus a face-to-face visit.
  • Be informed and made aware of the role of the Provider.
  • Be informed and made aware of the location of the Provider’s distant site and have all questions regarding the equipment, the technology, etc., addressed by your Provider.
  • Have the right to be informed of all parties who will be present during telehealth transmission.
  • Have the right to select another Provider and be notified that by selecting another Provider, there could be a delay in service and the potential need to travel for a face-to-face visit.
  • Depending on your state laws, your Provider may provide you with additional rights associated with telehealth.

8. Specific Informed Consent for Telehealth.

By signing below, you acknowledge that you understand and agree with the following:

  • I have read this document carefully and understand the risks and benefits of the telehealth consultation.
  • I give my informed consent to receive medical care and treatment by telehealth from the Medical Groups and their affiliated Providers.
  • I have the right to withhold or withdraw my consent to the use of telehealth at any time, without affecting my right to future care or treatment.
  • If I am experiencing a medical emergency, I have been directed to dial 9-1-1 immediately and that my Provider is not able to connect me directly to any local emergency services.
  • If I am thinking about suicide or if I am considering taking actions that may cause harm to myself or others, I have been directed to call 9-8-8 or to go to the nearest emergency room or to use the 24/7 crisis text line by texting “HOME” to 741-741.
  • I may elect to seek services from an unaffiliated medical group with in-person clinics as an alternative to receiving telehealth services.
  • I may expect the anticipated benefits from the use of telehealth in my care, but that no results can be guaranteed or assured.
  • Prior to the telehealth visit, I have been given an opportunity to review the Provider’s profile and credentials and to select a Provider I feel is appropriate for me.
  • Before the telehealth visit with my Provider begins, the Provider may explain additional rights and risks associated with telehealth. My Provider will also explain my diagnosis and its evidentiary basis, and the risks and benefits of various treatment options. I understand that I may ask my Provider questions regarding any aspect of the visit, and that I may at any time for any reason elect not to proceed with the telehealth visit.
  • I understand that someone other than my Provider might also be present during the consultation, including in order to operate the video equipment or provide translation services. If so, I understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (i) omit specific details of my medical history/physical examination that are personally sensitive to me; (ii) ask non-medical personnel to leave the telehealth examination room; and/or (iii) terminate the consultation at any time.
  • I understand that there is a risk of technical failures during the telehealth visit beyond the control of a Medical Group, my Provider(s), and/or Cerebral Inc.
  • In choosing to participate in a telehealth visit, I understand that some parts of the Services involving tests (e.g., labs or bloodwork) may be conducted at another location such as a testing facility, at the direction of my Provider.
  • It is necessary to provide my Provider a complete, accurate, and current medical history and that I understand that I can log into my Cerebral account at any time to access, review, amend, or request amendment of my health information. I understand that withholding or providing inaccurate information about my health and medical history in order to obtain treatment may result in harm to me, including, in some cases, death.
  • There is no guarantee that I will be issued a prescription, that the decision of whether a prescription is appropriate will be made solely in the professional judgment of my Provider, and that if my Provider issues a prescription, I have the right to select the pharmacy of my choice.
  • There is no guarantee that I will be treated by a Medical Group Provider and that I may need to seek medical care and treatment in-person or from an alternative source. My Provider reserves the right to deny care for potential misuse of the Services or for any other reason if, in the professional judgment of my Provider, the provision of the Services is not medically or ethically appropriate.
  • Federal and state law requires health care providers to protect the privacy and the security of health information. I understand that the laws that protect privacy and the confidentiality of health information also apply to telehealth, and that information obtained in the use of telehealth, which identifies me, are subject to policies, procedures and practices adopted by the Medical Groups that are designed to comply with HIPAA requirements and other applicable laws, and such laws govern which records resulting from the telehealth visit are part of my medical record.
  • The Medical Groups and Providers will protect and take commercially reasonable steps to make sure that my health information is not seen by anyone who should not see it. I understand that telehealth may, at the Provider’s discretion, involve electronic communication of my personal health information to other health practitioners who may be located in other areas, including out of state, and that my health information may be shared with other individuals for scheduling and billing purposes. Dissemination of any patient identifiable images or information from the telehealth visit to researchers or other educational entities will not occur without my affirmative consent.
  • I have the right to request a copy of my medical records at any time. Requests for a personal copy for my own use or requests to have a copy sent to my designated health care provider can be made by emailing: support@cerebral.com. I will not be charged for copies to be sent directly to my treating health care provider. Copies sent directly to me, for my own personal use, may have a reasonable cost of preparation, shipping, and delivery. I will be given an estimate of this cost before agreeing to pay.
  • I AGREE TO RELEASE AND HOLD HARMLESS THE MEDICAL GROUPS, CEREBRAL INC. AND THEIR AFFILIATES AND SUBSIDIARIES, AND EACH OF THEIR EMPLOYEES (INCLUDING PROVIDERS), CONTRACTORS, AGENTS, DIRECTORS, MEMBERS, MANAGERS, SHAREHOLDERS, OFFICERS, REPRESENTATIVES, ASSIGNS, PARENTS, PREDECESSORS, AND SUCCESSORS, FROM AND AGAINST ANY CLAIM, ACTIONS, PROCEEDINGS, DEMANDS, DAMAGES, LOSSES, LIABILITIES, SETTLEMENTS, COSTS AND EXPENSES, INCLUDING, WITHOUT LIMITATION, REASONABLE LEGAL AND ACCOUNTING FEES AND LITIGATION EXPENSES RESULTING OR ARISING FROM, OR ALLEGED TO RESULT OR ARISE FROM, DELAYS IN EVALUATION, INFORMATION LOST DUE TO TECHNICAL FAILURES AND/OR THE RISKS SET FORTH ABOVE.

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.

  • Relevant Board Contact Information:
    Board of Professional Counselors
    Division of Corporations, Business & Professional Licensing
    P.O. Box 110806, Juneau, AK 99811-0806 
    Phone: (907) 465-2551
    Email: ProfessionalCounselors@Alaska.Gov

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)).

  • Relevant Board Contact Information:
    Board of Behavioral Health Examiners
    1740 West Adams Street, #3600, Phoenix, AZ 85007
    Main Number: 602-542-1882
    Fax Number: 602-364-0890
    Email: information@azbbhe.us

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.

  • Relevant Board Contact Information:
    State Board of Licensed Professional Counselor Examiners, State Board of Social Work Examiners, State Board of Marriage and Family Therapist Examiners, State Board of Addiction Counselor Examiners, and State Board of Psychologist Examiners
    1560 Broadway, Suite 1350, Denver, Colorado 80202
    Phone: (303) 894-7800
    Email: DORA_Customercare@state.co.us

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)).

  • Relevant Board Contact Information:
    Connecticut Department of Public Health
    Professional Counselor Licensure
    410 Capitol Ave., MS #12 APP, P.O. Box 340308, Hartford, CT 06134
    Phone: (860) 509-7603
    Fax: (860) 707-1980
    Email:  dph.counselorsteam@ct.gov

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).

  • Relevant Board Contact Information:
    Professional Counseling Licensing
    899 North Capitol Street, NE, Washington, DC 20002
    Phone: (202) 442-5955
    Fax: (202) 442-4795

    Department of Health Board of Medicine
    899 North Capitol Street, NE, Washington DC, 20002
    Email: doh@dc.gov

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)).

  • Relevant Board Contact Information:
    Georgia Composite Medical Board
    2 Peachtree Street, NW, 6th Floor, Atlanta, GA 30303-3465
    Email: medbd@dch.ga.gov

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.

  • Relevant Board Contact Information:
    Idaho Board of Medicine
    11341 W. Chinden Blvd, Building #4, Boise, ID 83714
    Phone: (208) 327-7000
    Email: BOM-info@dopl.idaho.gov

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

  • Relevant Board Contact Information:
    Illinois Department of Financial and Professional Regulation
    Chicago: 555 West Monroe St., 5th Floor Chicago, IL 60661
    Springfield: 320 W. Washington Street, 3rd Floor, Springfield IL
    Phone: 1 (888) 473-4858

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/

  • Relevant Board Contact Information:
    Office of the Indiana Attorney General
    Consumer Protection Division
    302 W. Washington Street, 5th Floor, Indianapolis, IN 46204
    Phone: (317) 232-6330 or (800) 382-5516

    Indiana Professional Licensing Agency
    Indiana Government Center South, Room W072, 402 West Washington Street, Indianapolis, IN 46204
    Phone: (317) 232-2960

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

  • Relevant Board Contact Information:
    Iowa Board of Medicine
    400 SW 8th Street, Suite C, Des Moines, IA 50309
    Phone: (515) 281-5171

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

  • Relevant Board Contact Information:
    Kansas Board of the Healing Arts
    800 SW Jackson, Lower Level - Suite A, Topeka, KS 66612
    Phone: (785) 296-7413
    Fax (785) 368-7102

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

  • Relevant Board Contact Information:
    Kentucky Board of Medicine
    310 Whittington Parkway, Suite 1B, Louisville, KY 40222
    Phone: (502) 429-7150

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).

  • Relevant Board Contact Information:
    Licensed Professional Counselors Board of Examiners
    11410 Lake Sherwood Ave North Suite A, Baton Rouge, LA 70816
    Phone: (225) 295-8444 
    Fax: (225) 295-8448 (fax)
    Email: lpcboard@lpcboard.org

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

  • Relevant Board Contact Information:
    Maine Board of Licensure in Medicine
    137 State House Station, 161 Capitol Street, Augusta, Maine 04333
    Phone: (207) 287-3601
    TTY users call Maine relay 711
    Fax: (207) 287-6590
    Complaints: (888) 365-9964

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

  • Relevant Board Contact Information:
    Maryland Board of Physicians
    4201 Patterson Avenue, Baltimore, MD 21215
    Phone: (410) 764-4777

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).

  • Relevant Board Contact Information:
    Office of Professional Licensure & Certification
    7 Eagle Square, Concord NH, 03301
    Phone: (603) 271-2152

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).

  • Relevant Board Contact Information:
    New Jersey Board of Medical Examiners
    Email: bme@dca.lps.state.nj.us
    Phone: (609) 826-7100

    Professional Counselors Examiners
    Email: MFTinquiries@dca.njoag.gov
    Phone: (973) 504-6582

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/

  • Relevant Board Contact Information:
    Oklahoma Board of Medical Licensure
    101 NE 51st Street, Oklahoma City, OK 73105
    Phone: (405) 962-1400

    Oklahoma Board of Osteopathic Examiners
    4848 N. Lincoln Blvd. Suite 100, Oklahoma City, OK 73105
    Phone: (405) 528-8625

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

  • Relevant Board Contact Information:
    The Board of Licensed Professional Counselors and Therapists 
    3218 Pringle Rd SE, #120, Salem, OR 97302-6312
    Phone: (503) 378-5499 Email: lpct.board@state.or.us
    Website: www.oregon.gov/OBLPCT

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).

  • Relevant Board Contact Information:
    State Board of Social Workers, Marriage and Family Therapists and Professional Counselors
    P.O. Box 2649, Harrisburg, PA 17105-2649 
    Phone: (717) 783-1389

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.

  • Relevant Board Contact Information:
    South Carolina Board of Examiners for The Licensure of Professional Counselors, Marriage and Family Therapists, and Psycho-educational Specialists
    P.O. Box 11329, Columbia, South Carolina 29211-1329 
    Phone: (803) 896-4652

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.

  • Relevant Board Contact Information:
    Tennessee Department of Health
    710 James Robertson Parkway, Nashville, TN 37243
    Email: tn.health@tn.gov

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

  • Relevant Board Contact Information:
    Texas Medical Board
    333 Guadalupe, Tower 3, Suite 610, Austin, Texas 78701
    Phone: (512) 305-7010

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).

  • Relevant Board Contact Information:
    Utah Medical Board
    Phone: (801) 530-6628,
    (866) 275-3675
    Email: b1@utah.gov

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/

  • Relevant Board Contact Information:
    Vermont Board of Medical Practice
    108 Cherry Street, PO Box 70, Burlington, VT 05402
    Phone: (802) 657-4220

    Vermont Office of Professional Regulation
    89 Main Street, 3rd Floor, Montpelier, VT 05620
    Phone: (802) 828-1505

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.

  • Relevant Board Contact Information:
    Washington State Department of Health
    Health Professions Quality Assurance
    P.O. Box 47865 Olympia, WA 98504-7865
    Phone: (360) 236-4700

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.                   

Medication Management  

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)

Cerebral logoCerebral logoCerebral logo
If you're in emotional distress, here are some resources for immediate help:
Emergency:
Call 911
National Suicide Prevention Hotline:
Call 988
Crisis Text Line:
Text Home to 741-741
Let’s stay in touch
facebookinstagramlinkin
Google Play ButtonApp Store Button