This is an important notice about your informed consent to use behavioral telehealth services from Empowering Relief Counseling, PLLC (ERC). This document outlines some important rights and responsibilities and is an addition to the Professional Service Agreement you signed when you started services at ERC. If you have questions or concerns and/or do not consent to services as outlined below, please discontinue use of our virtual service and contact your therapist.
By proceeding to use telehealth services at ERC, you acknowledge your understanding that “telehealth” includes the practice of health care delivery, mental health assessment, diagnosis, consultation, treatment/psychotherapy, treatment planning, transfer of medical data, and education using interactive audio, video, or data communications. ERC uses a secure web-based system through our electronic medical record, TheraNest, to transmit audio and video data. To ensure privacy, the data is encrypted at the highest level possible and in compliance with HIPAA.
While participating in telehealth at ERC, you have the following rights and responsibilities:
(1) You have the right to withhold or withdraw consent 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 you would otherwise be entitled.
(2) Everything outlined in ERC’s Professional Service Agreement, which you have been provided, applies equally to telehealth and face-to-face services.
(3) The laws that protect the confidentiality of your medical information also apply to telemedicine. As such, the information disclosed by you during the course of therapy is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality as outlined in ERC’s Professional Service Agreement. As one of those exceptions, if your counselor believes your safety is at risk, they will contact emergency services and provide details that may otherwise be held in confidence.
(4) The dissemination of any personally identifiable images or information from the telehealth interaction to a third party shall not occur without your written consent.
(5) There are risks and consequences involved in telehealth services, including, but not limited to, the possibility, despite reasonable efforts on the part of ERC, that:
a. the transmissions of your medical information could be disrupted or distorted by technical failures;
b. the transmission of your medical information could be interrupted by unauthorized persons;
c. and/or the electronic storage of your medical information could be accessed by unauthorized persons.
All attempts to keep information confidential while using the web-based systems utilized for telehealth services will be made but a guarantee of 100% confidentiality cannot be made as a result of inherent risks with these communication systems. By continuing to use telehealth services, you attest you understand these issues and consent to use these systems for telehealth services.
(6) Telehealth-based services and care may not be as complete as face-to-face service. If your counselor believes you would be better served by another form of psychotherapy (e.g. face-to-face services) you will be asked to schedule a session at the office, or you will be referred to another clinician who can provide such services in your area.
(7) There are potential risks and benefits associated with any form of psychotherapy and results cannot be guaranteed or assured. Accordingly, despite your efforts and the efforts of your counselor, your condition may or may not improve, and in some cases, may even worsen.
(8) Nobody besides your counselor will be present at the therapist’s designated site during the provision of telehealth services unless you are otherwise notified and provide your consent. ERC cannot be held responsible or liable for maintaining confidentiality at the site in which you choose to participate in telehealth services.
(9) You have a right to access your medical information and copies of medical records in accordance with state and federal law and ERC policies and procedures.
(10) Certain situations, including emergencies and crises, are inappropriate for telehealth services. If you are in crisis or in an emergency, you should immediately call 911 or go to the nearest hospital or crisis facility. Emergency situations may include thoughts about hurting or harming yourself or others, having uncontrolled psychotic symptoms, any life threating or emergency situation, and/or abuse of drugs or alcohol that may jeopardize your safety. You can access crisis line telephone numbers by visiting https://ercounseling.com/resources (e.g. University Neuropsychiatric Institute, 501 Chipeta Way, Salt Lake City, Utah 84108, 801-587-3000). You are advised to access these services should the need arise.
By logging on and continuing the use of telehealth services through ERC, you acknowledge you have read and understand the information provided above. In addition, you consent to ongoing services in compliance with the terms and conditions above.
If you are providing consent for telehelath services on behalf of your child, you attest you are legally permitted to consent for your child’s care and agree to the terms and conditions above on behalf of your child.