PMT Telehealth Consent
The purpose of this form is to obtain your consent to participate in telehealth services per the advisement of the American Music Therapy Association (
1) Purpose and Benefits. The purpose of this telehealth consent is to establish or maintain access to music therapy services when face-to-face contact is restricted or not available.
2) Nature of Music Therapy Telehealth Services: a) Details of you and/or your child’s medical history, music therapy assessment, or treatment objectives may be discussed through the use of interactive video, audio and telecommunications technology. b) List Services Provided: Music Therapy Treatment Individual Sessionc) Nonmedical technical personnel may be present in the telehealth studio to aid in video transmission. d) Video, audio, and/or digital photo may be recorded during the telehealth visit.
3) Medical Information and Records. All existing laws regarding your access to medical information and copies of your medical records apply to telehealth visits. Additionally, dissemination of any patient-identifiable images or information from this telehealth interaction to researchers or other entities shall not occur without your consent, unless authorized under existing confidentiality laws.
4) Confidentiality. Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with telehealth visits. All existing confidentiality protections under federal and State (North Carolina & South Carolina) Laws apply to information disclosed during telehealth visits.
5) Risks and Consequences. Telehealth visits will be similar to typical visits, except interactive video technology will allow you to communicate with the music therapist at a distance. At first you may find it difficult or uncomfortable to communicate using video images. The use of video technology to deliver healthcare and educational services is a new technology and may not be equivalent to direct patient to professional contact.
6) Rights. You may withhold or withdraw consent to telehealth visits at any time without affecting your right of future care or treatment, or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled.
7) Financial Agreement. Telehealth appointments will be billed electronically on the day of a service.
Email *
Client's First & Last Name *
I have been advised of all the potential risks, consequences and benefits of telehealth services. My music therapist has discussed with me the information provided above. I have had an opportunity to ask questions about this information and all of my questions have been answered. By writing my FULL NAME, I understand the written information provided above. *If client does not sign their full name, list relationship of individual consenting to telehealth. For example: "Harmony Huggins, Parent" or "Melody Modal, Client." ** *
Please date this consent: *
Please list the time of this consent: *
Thank you for providing consent for Telehealth Appointments provided by the Board Certified Music Therapists on Staff at Piedmont Music Therapy, LLC. We are proud to work with individuals of all abilities in Greater Charlotte of the Carolinas. #safetyiskey
Never submit passwords through Google Forms.
This form was created inside of Piedmont Music Therapy, LLC. Report Abuse