Consent for Telehealth
What is it?
The American Speech and Hearing Association (ASHA) defines telepractice (the act of providing Telehealth services) as "the application of telecommunications technology to delivery of professional services at a distance by linking clinician to client, or clinician to clinician, for assessment, intervention, and/or consultation." It is important to know that this service delivery model is supported through the Texas licensing board, the American Speech-Language Hearing Association (ASHA), and is payable by most insurance carriers per the Telehealth Enhancement Act of 2013- H.R.3306, 113th Congress. Holland does not directly bill insurance companies. Invoices reflecting speech therapy sessions provided through telepractice will be coded accordingly. When implementing this mode of service delivery based on ASHA guidelines and ethics, research has shown that telepractice has equal outcomes to face-to-face interventions.
I hereby consent to engage in teletherapy with Holland Speech & Consulting, LLC (HSC). I understand that “teletherapy” includes treatment using interactive audio, video, or data communications. I understand that teletherapy also involves the communication of my medical information, both orally and visually. I understand the following with respect to teletherapy: I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment. The laws that protect the confidentiality of my medical information also apply to teletherapy. As such, I understand that the information disclosed by me during the course of my therapy or consultation is confidential. I understand that there are risks and consequences from teletherapy, including, but not limited to, the possibility, despite reasonable efforts on the part of HSC, that: the transmission of my information could be disrupted or distorted by technical failures; the transmission of my information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons.
HSC currently uses Zoom Healthcare to provide teletherapy services. I understand that I am responsible for (1) providing the necessary computer, telecommunications equipment and internet access for my teletherapy sessions, (2) the information security on my computer, and (3) arranging a location with sufficient lighting and privacy that is free from distractions or intrusions for my teletherapy session. Teletherapy has been determined as an appropriate service delivery model for this patient. Teletherapy will only be used if determined to be at least as effective as in-person treatment. If teletherapy is not deemed as effective, you will be notified. In order to participate in teletherapy, the patient must first participate in an in-person evaluation. For certain individuals, we ask that an adult facilitator be present in the room for assisting with technical difficulties, or keeping a child on task. Teletherapy may be used as the primary means of service delivery, or may be used in combination with in-person services.
Patient's Date of Birth
I have read, understand and agree to the information provided above
By checking this, you are eSigning this form.
I do NOT consent to telehealth services
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