Telehealth Patient Consent Form
Telehealth, also known as Telemental Health or Telebehavioral Health, is the delivery of mental health services using interactive audio and visual electronic systems between a provider and a patient that are not in the same location. These services may also include electronic prescribing, appointment scheduling, communication via email or electronic chat, and distribution of patient education materials. Desai Health utilizes secure, encrypted audio/video transmission software to deliver telehealth.
I understand that I have the following rights with respect to Telehealth:
1. I have the right to withhold or withdraw consent at any time without affecting my access to future care, treatment, services or benefits to which I would otherwise be entitled.
2. The laws that protect the confidentiality of my personal information also apply to telehealth. As such, I understand that the information disclosed by me during the course of treatment is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality including, but not limited to, reporting of child, elder and dependent adult abuse; expressed threats of violence towards an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding. I also understand that the dissemination of any personally identifiable images or information from the telehealth interaction to other entities shall not occur without my written consent.
3. I understand that there are risks and consequences from telehealth, including, but not limited to, the possibility, despite reasonable efforts on the part of the provider, that: the transmission of my personal information could be disrupted or distorted by technical failures, the transmission of my personal information could be interrupted by unauthorized persons, and/or the electronic storage of my personal information could be unintentionally lost or accessed by unauthorized persons.
4. Telehealth may not be as complete as face-to-face services. I understand that if my provider believes I would be better served by another form of intervention (e.g., face-to-face services), I may be referred to a mental health provider who can provide such services in my area. I also understand there are potential risks and benefits associated with any form of psychiatry or psychotherapy and that despite my efforts and the efforts of my provider, my condition may not be improved, and in some cases may even worsen.
5. I understand that I may benefit from telehealth via improved access to care and more efficient evaluation and management from the use of telehealth in my care, but that no results can be guaranteed or assured.
6. I understand that I have the right to access my medical information and records in accordance with Florida law.
Desai Health will bill insurance for telehealth services; however, it is the responsibility of the patient (parent/guardian) to verify coverage of telehealth prior to services being rendered.
By signing this document, I agree that certain situations, including emergencies and crises, are inappropriate for telehealth services. If I am in crisis or in an emergency, I should immediately call 9-1-1 or seek help from a hospital or crisis-oriented health care provider/facility in my area. I also agree not to record any telehealth sessions without written consent from my provider and understand that my provider will not record any sessions without my written consent.
Patient Name: _________________________________________
Signature: ___________________________________ Date: _______________________
Relationship of the signer to the patient: _____ self _____ parent/guardian _____ legal representative
If you have insurance, we will make every effort to assist you with your carrier to make sure your treatment is authorized and reimbursement
Is received. However, our professional services are rendered to you, not the insurance company. Therefore, payment for services is ultimately your responsibility. If your insurance company fails to pay, for any reason, it is your responsibility to pay for services rendered and such payment is not contingent on settlement, judgement, or insurance payment by which you may recover said fees.
ALL CO-PAYMENTS ARE TO BE PAID AT THE TIME OF THE VISIT. Any exceptions are at the discretion of the provider and will need to be agreed to prior to being seen. Applicable deductibles may be required at the time of the visit or may be billed to you after insurances has processed. If you fail to make timely payments on your account, as agreed upon, your account will be turned over to a collection agency and you will be assessed a 40% collection fee. If your account is placed with a collection agency you will be discharged from the practice.
Our office must be notified of any insurance changes PRIOR to your next appointment so that we can verify eligibility and benefits. If you do not inform us of any changes, you will be responsible for any charges not covered by your insurance company.
There is a $50 fee for all returned checks. Returned checks are not re-deposited and if not paid may be turned over to a collection agency of the State Attorney’s office. After your 2nd returned check we will require payment in the form of cash or credit card only.
Self-pay patients are billed per amount of time scheduled and payment is expected prior to seeing your provider. In case of late arrival, you will still be billed for the full amount of time originally scheduled.
Evaluation: M.D. = $300 APRN = $250 THERAPIST = $200
Follow-up visits: M.D. = $175 APRN = $150 THERAPIST = $150
Phone Consults: M.D. = $65 per 10 mins APRN = $55 per 10 mins THERAPIST = $25 per 10 mins
Letters/Forms: fees based on complexity and time spent on completion
Request for Emotional Support Animal: Our office does not provide medical documentation for emotional support animals.