When utilizing telehealth, please take a few minutes to read through this document and provide consent to our services. Telehealth Consent Today's Date: MM slash DD slash YYYY Client Name First Last Date of Birth MM slash DD slash YYYY Northland Counseling Center, Inc Telehealth Consent* I consent to Northland Counseling Center, Inc and its satellite office to use telehealth for my appointments.PURPOSE: The purpose of this form is to obtain your consent to participate in telemedicine services in connection with the following services provided by Northland Counseling Center, Inc. and all satellite offices associated within. Services may include: Individual Therapy, Diagnostic Assessments, Medication Management, Psychiatric Consultations, Adult Rehabilitative Mental Health Services (ARMHS), Peer Support Services (PSS), Housing Services, Employment Services through Northern Opportunities Works (NOW), Crisis Assessments, Crisis Interventions, Crisis Stabilization, Intakes, Clinical Care Consultation, Case Management, DBT Services, Substance Use Disorder (SUD) treatment (assessments, treatment planning, BHH, individual/group services) and Children’s Therapeutic Supports and Services (CTSS). INTRODUCTION: Telemedicine involves the use of electronic communications to enable office visits from a site other than Northland Counseling Center, Inc. ‘Telemedicine’ means using electronic systems to allow communication between a client and a provider who are in different locations. CONFIDENTIALITY: Northland Counseling Center, Inc. utilizes Zoom, which incorporates networking software security protocols to protect confidentiality of patient identification and will include measures to safeguard data and to ensure the integrity against intentional or unintentional corruption. Reasonable and appropriate efforts have been made to illuminate any confidentiality risks associated with the telemedicine consultation and all existing confidentiality protections under Federal and Minnesota State Law applied information disclosed while utilizing telemedicine services. RIGHTS: You may withhold or withdraw consent to telemedicine services at any time without affecting your right to future services with Northland Counseling Center, Inc. or risk the loss or withdrawal of any program benefits to which you would otherwise be entitled. RISKS, CONSEQUENCES and BENEFITS: In rare cases, the information transmitted may be inadequate quality or, if the equipment is not working, there could be delays in evaluation and treatment. In these cases, the visit maybe rescheduled or your provider will discuss Face-to-Face visit needs. You or your mental health provider may discontinue the telehealth visit if the connections are not adequate for the situation. Very rarely, security protocols could fail, causing a breach of privacy of medical information. Northland Counseling Center, Inc. has implemented appropriate security measures to mitigate against this rare situation. By checking the box below, I indicate that Northland Counseling Center, Inc. has my permission to use a web-based video-conferencing application to facilitate my care and treatment. • I understand the expiration date of this authorization is 1 year from today’s date note above. • I understand that my Protected Health Information (PHI) will be transmitted by a third party web-based video conferencing vendor to my provider during my telehealth visits. • I understand that I have the right to revoke my permission at any time. I understand I must make my request in writing to Northland Counseling Center, Inc. Name of person filling out the form: First Last Relationship to Client: Consent* by Checking this box I agree to the telehealth policyIf you are signing for a minor child or someone you have guardianship over by checking the box you indicate that you agree to the policy for that individual. Thank you!
