Telepsychiatry Agreement
Telepsychiatry involves the use of electronic communications to enable Alliance Psychiatry LLC and Alliance Psychiatry Partners LLC clinicians ("Providers") to connect with individuals using live interactive video and audio communications. Telepsychiatry includes the practice of psychiatric and mental healthcare delivery, diagnosis, consultation, treatment, referral to resources, education, and the transfer of medical and clinical data.

Providers utilize secure, encrypted HIPAA compliant audio/video transmission software to deliver telehealth via Google Business G Suite Meet (formerly called Hangouts).

Providers follow the State of Maryland COMAR Regulations for telehealth: 10.32.05 as well as their respective board regulations and ethics. They have also received training to provide telehealth services.

Patients must be physically located within the state in which their provider is licensed at the time of the telepsychiatry visit*. Dr. Kirsten George is licensed in MD and PA; and James Park is licensed in MD.

I understand that I have the following rights with respect to telepsychiatry:

1. The laws that protect the confidentiality of my personal information outlined in the HIPAA privacy notice that I will sign or have already signed also apply to telepsychiatry. A copy of our Policies and Procedures are available upon request.

2. I understand that I have the right to withhold or withdraw my consent to the use of telepsychiatry in the course of my care at any time, without affecting my right to future care or treatment.

3. By scheduling telepsychiatry appointments and agreeing to the Policies and Procedures, I agree that certain situations, including emergencies and crises, are inappropriate for audio-/video-/computer-based mental health services. If I am in crisis or in an emergency, I should immediately call 9-1-1 or seek help from an Emergency room or crisis-oriented health care facility in my immediate area.

*During the COVID-19 pandemic, this restriction has been loosened in many states.
Consent *
Full Name *
Date of Birth *
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