Claudelle R. Glasgow, Psy.D., SEP

Licensed Psychologist

(312) 804 – 3079

drcrglasgow@gmail.com

4225 NE Tillamook St Portland, OR 97213

Addendum to Patient Services Agreement:

Telehealth Consent

For those of you who wish to have Zoom, video conferencing, or phone sessions with

me, please read the following and sign if this is acceptable to you.

HIPAA laws are the laws related to privacy rights of information shared with me as your

clinician, as well as information that gets transmitted to your insurance companies. Some of

the forms you signed early on about privacy rights, Consent to Release Information, etc are

related to this. They are rather extensive and cover issues as varied as how patient and

clinician can communicate among themselves and with others, and the nature of the

information communicated.

As well, we are beginning to be able to communicate via Zoom, video conferencing, and

phone sessions. These types of sessions are often convenient and useful when a face-to-face

session is not possible.

It is necessary that I inform you that even with telehealth laws and guidelines, there is still

the potential threat of hacking and unauthorized access to PHI (personal health information).

In other words, telephone sessions, video conferencing, and Facetime sessions do not have

the same guarantee of privacy as face-to-face sessions in my office.

Please note that your insurance company (with the exception of Medicare) may cover video

telehealth sessions, but as of now telephone sessions are usually not a covered benefit.

Therefore, if you choose a modality not covered by insurance, the full fee will be your

responsibility.

Name: ____________________________

Signature: ____________________________

Date: ____________________________