Compass Tree, LLC Telehealth Guidelines
(Please note that this agreement is only valid during the current Coronavirus outbreak. Once our area is no longer considered in a state of emergency, the contract will be terminated.)
HIPAA CONFIDENTIALITY AGREEMENT
All protections and limitations of HIPAA are the same for online therapy and phone contact, as they are in person, as outlined in the policy.
It is critical to maintain a setting, as similar as possible, to that of being in an office together. In order to have effective online therapy sessions, the following guidelines must be followed:
1. Your device must be placed on a steady surface and not held in your hand, if at all possible. If you must hold your device, please keep it as steady as you can. You should remain in the same location the entire session and avoid moving around.
2. Select a private location where your session cannot be overheard by others and adjust the volume on your device to ensure privacy. You are required to inform your provider if there is anyone in the room with you, or if you believe someone may overhear the session.
3. Make sure you are located at one of the designated sites pre-approved by your insurance if an “originating site” is a requirement. If you are unsure, ask your provider before you schedule.
4. You must always be decently attired, and no underclothing will be permitted.
5. No provocative postures or gestures will be tolerated.
6. Minimize background noise by turning off TVs, music, and other sounds. Make sure to close the door to the room you are in.
7. Eliminate distractions by not playing games on your device, avoiding social media, and focusing on other things around you. Make sure that pets, children, household members, and roommates will not be a distraction from therapy.
8. You may not invite others in during the session without asking the provider first.
9. If the connection is broken for any reason, your provider will call you back to try to remedy the situation.
10. All screenshots, photos, and recordings are strictly prohibited. They will result in immediate termination of the session, online services, and possibly discharge from the practice.
Your balance must be paid in full at the time of service. A fee of $25.00 will be charged for late cancellations if 24 hours’ notice is not given. You will be charged $100.00 for missed appointments.
I consent to online therapy (TeleHealth)
I agree to abide by the guidelines above during online contact.
I agree to pay for the entire session if my insurance does not cover TeleHealth services, and if my insurance does cover TeleHealth services, I agree to pay my deductible, copayment, or coinsurance based on the benefits outlined in my policy.
I agree to pay $25.00 for all late cancellations and $100.00 for all missed appointments.
I agree to allow the use of my email for Telehealth and to receive updates and information
By submitting this form you are providing your signature as an authorized individual agreeing to the use and terms of teleheath stated above for the client listed.
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This form was created inside of Compass Tree LLC.