Telemedicine Service Agreement

  • Telemedicine Services Agreement

    Brave Soul Counseling Services emphasizes the importance of the face-to-face relationship with a client, however, there are a variety of reasons for why this is not always possible. In those circumstances, telemedicine services may serve as an effective alternative.

    Telemedicine services provides an opportunity for clinicians to conduct mental health services through electronic means such as audio and video communication.

    By signing this form, I am aware that I have the following rights and responsibilities:

    1. Telemedicine is confidential. Any personal information I choose to share with my therapist(s) will be held in the strictest confidence. Brave Soul Counseling will not release any information without prior approval or as required by law, including mandated reporting laws.
    2. Telemedicine sessions are not to be recorded by either the therapist or the client.
    3. It is important, in case of emergency, that my therapist knows my location at the beginning of every session.
    4. I understand that if I am having a mental health crisis or emergency, I will call 911 or my local crisis unit because I understand that telemedicine would not be appropriate at a time like this.
    5. I understand that there are risks associated with telemedicine. Risks include the potential release of private information due to the problems that may arise with the internet and phone systems. I also understand that viruses and other involuntary intrusions may inadvertently lead to confidential information being shared. I understand that it is my responsibility to secure a private location for the therapy to occur and it is also my responsibility to manage my own internet security on my device. Brave Soul Counseling will use or an alternative HIPAA compliant platform for telemedicine services.
    6. Internet and audio connections sometimes fail, and I am aware that if the connection cannot be maintained, the session may need to be canceled and/or rescheduled.
    7. I understand that my therapist is governed by the laws of the State of MN regarding telemedicine services and as such, I am consenting to telemedicine services only in the state of MN.
    8. I am aware that if I relocate or change my legal residence to a location outside of Minnesota, I will no longer be able to continue telemedicine services and must determine an appropriate continuity of care plan with my therapist.
    9. I understand that there may be circumstances in which the therapist deems face-to-face therapy is more effective for me or my presenting situation and has a right to change service arrangements.
    10. Most insurance companies will provide coverage for telemedicine services; however, I am responsible for both ensuring my plan covers telemedicine services, and/or paying any expenses not covered by my insurance provider and plan.
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