Please complete the form below to provide informed consent for our telehealth services.

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This informed consent is a supplement to the General Informed Consent that all clients sign and does not amend any of the terms of that agreement. Clients only need to fill out this consent if they are electing to receive services via telehealth. There are no known risks associated with receiving care this way and participation is voluntary. The client may elect to stop participation at any point and switch to regular office visits, or discontinue care all together. Telehealth visits can be advantageous for: bad weather, car problems, illness, work conflicts that don’t allow time to come to the office, anxiety about travel or driving, or simply personal preference for ease and convenience. Most insurance companies cover telehealth visits similar to office visits. IPC will do its best to check if a client’s plan allows for it, but it is ultimately the responsibility of the client to know and find out what the client’s plan covers prior to starting services.

The client’s confidentiality and privacy will be protected by IPC. However remote and unlikely, there is always the possibility of ideoconference being intercepted by an outsider. IPC uses a HIPAA compliant software that is encrypted for additional security in order to reduce these risks. IPC staff will always be in a secure location, with doors closed, and be alone in the room; just as they are in an office visit. The client’s living situation may have the potential for others to overhear sessions, so it is up the individual client to make sure they are in a private location. IPC does not record telehealth visits.

If the client or the provider runs into a technology problem and the connection is broken, IPC will attempt to make the connection again. If a connection cannot be made, the provider will contact the client with the phone number provided to discuss finishing the session on the phone, or reschedule the visit. The client’s signature below signifies that the client is electing to receive health care services through interactive videoconferencing equipment. The client understands that telehealth is bound by all the same terms, conditions, laws, and rules that regular office visits entail. The client understands that telehealth visits will be documented like any office visit and become a part of the client’s medical record.

The client’s signature below signifies that the client has read this document and consents to participate in receiving telehealth services under the terms described above and in accordance with the General Informed Consent Agreement.

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