(833) 688-2274
Facebook Instagram Linkedin
Book an appointment

Informed Consent for Telehealth

Introduction

This document contains important information about providing psychiatric services using telehealth. Please read this carefully and sign to indicate your informed consent to receive telehealth services.

Nature of Telehealth Services

Telehealth involves the use of electronic communications (video conferencing via Healthie’s platform) to enable healthcare providers to deliver psychiatric services remotely. Services provided include psychiatric evaluations, medication management, and psychoeducation.

Expected Benefits

  • Increased accessibility to psychiatric care
  • Convenience of receiving care from your location of choice
  • Reduced need to travel to receive psychiatric care
  • Continuity of care regardless of geographic location within Illinois

Potential Risks

  • Technical difficulties may disrupt or delay service delivery
  • Despite security measures, electronic transmission may be disrupted or distorted by technical failures
  • In rare cases, security protocols could fail, causing a breach of privacy
  • Limited ability to respond to emergencies directly
  • Insurance benefits may not cover some telehealth services

Technology Requirements

  • Access to a stable internet connection
  • Device with video and audio capabilities (computer, tablet, or smartphone)
  • Private location to ensure confidentiality of sessions
  • Access to a telephone as backup

Privacy and Security Measures

  • Sessions are conducted through Healthie’s HIPAA-compliant telehealth platform
  • Sessions are not recorded
  • All electronic communications are encrypted
  • Staff access to information is restricted and monitored

Your Rights and Responsibilities

You have the right to:

  • Withdraw this consent at any time
  • Ask questions about the telehealth process
  • Receive services in-person instead of via telehealth (if available)
  • Be informed of alternatives to telehealth


You are responsible for:

  • Ensuring you have a private space for sessions
  • Maintaining the privacy of your login credentials
  • Notifying provider of your location at start of each session
  • Having a backup phone available for technical difficulties
  •  

Emergency Protocol

In case of an emergency during a telehealth session:

  • Provider will attempt to contact you directly
  • If unreachable, provider may contact emergency services or your emergency contact
  • You should seek immediate help at your nearest emergency room if needed

Technical Difficulties Protocol

If video connection fails:

  1. Provider will attempt to reconnect to the video session
  2. If reconnection fails, provider will contact you via phone
  3. If phone connection isn’t possible, session will be rescheduled

Fees and Insurance

  • Standard service fees apply to telehealth sessions
  • Insurance coverage for telehealth services may vary
  • You are responsible for confirming coverage with your insurance provider

Consent

By signing, you confirm that:

  • You have read and understand the information provided above
  • You agree to receive psychiatric services via telehealth
  • You understand the risks and benefits of telehealth services
  • You have had the opportunity to ask questions about this information