CONSENT FOR TELE-PSYCHIATRY

Introduction

Tele-psychiatry is the delivery of psychiatric services using interactive audio and visual electronic systems between a provider and a patient that are not in the same physical location. The interactive electronic systems used inTele-psychiatry incorporate network and software security protocols to protect the confidentiality of patient information and audio and visual data. These protocols include measures to safeguard the data and to aid in protecting against intentional or unintentional corruption.

Potential Benefits

Tele-psychiatry provides convenience and increased accessibility to psychiatric care for individuals who are unable to be treated face to face due to temporary circumstances such as an extended stay away from home or having a physical limitation preventing travel to my office, or public imposed restrictions and quarantines.

          •      Tele-psychiatry provides convenience and increased accessibility to psychiatric care for individuals who are unable to be treated face to face due to temporary circumstances such as an extended stay away from home or having a physical limitation preventing travel to my office, or public imposed restrictions and quarantines.          •

Potential Risks

As with any medical procedure, there may be potential risks associated with the use of Tele-psychiatry. These risks include, but may not be limited to:

•       Information transmitted may not be sufficient (e.g., poor resolution of video) to allow for me to make appropriate decisions

•       I may not be able to provide medical treatment using interactive electronic equipment nor provide for or arrange for emergency care that you may require.

•       Delays in medical evaluation and treatment may occur due to deficiencies or failures of the equipment.

•       A lack of access to all the information that might be available in a face-to-face visit, but not in a Tele-psychiatry session, may result in errors in judgment.

          •      Security protocols can fail, causing a breach of privacy of confidential health information. I try to use software that meets the HIPAA recommended standards to protect the privacy and security of the Tele-psychiatry sessions. However, the service cannot guarantee total protection against hacking or tapping into the Tele-psychiatry session by outsiders. This risk is small, but it does exist.

Alternatives to the Use of Tele-psychiatry

•       Traditional face-to-face sessions in my provider’s office or meeting by telephone, which may be even less secure than videoconferencing software.

Patient’s Rights

·       I have the right to withhold or withdraw my consent to the use of Tele-psychiatry during the course of my care at any time. I understand that my withdrawal of consent will not affect any future care or treatment.

•       I understand that Dr. Komrad has the right to withhold or withdraw consent for the use of Tele-psychiatry during the course of my care at any time if he does not believe Tele-psychiatry care is safe or meets professional standards of care.

·       I understand that the laws that protect the privacy and confidentiality of medical information also apply to Tele-psychiatry.

·       I understand that the all rules and regulations that apply to the provision of healthcare services in the State of Maryland also apply to Tele-psychiatry.

Patient’s Responsibilities

·       I will not record any Tele-psychiatry sessions without written consent from Dr. Komrad. I understand that he will not record any of our Tele-psychiatry sessions without my written consent.

·       I will inform Dr. Komrad if any other person can hear or see any part of our session before the session begins. I will do my best to maintain privacy during our sessions and minimize distractions (i.e. others in the home, pets).

·       Dr. Komrad  will inform me if any other person can hear or see any part of our session before the session begins.

·       At each session, I will give Dr. Komrad a backup phone number in case we should lose connection/video or audio and the address at which I am receiving the Tele-psychiatry appointment.

·       I agree to an emergency plan, if necessary,  including calling 911 or other emergency responder number, going to the nearest ER, or contacting other community urgent resources, including a mobile crisis center.

·       I consent for Dr. Komrad to contact my emergency contact person if clinically necessary.

·       I understand that I, not my provider, am responsible for the configuration of any electronic equipment used on my computer that is used for Tele-psychiatry. I understand that it is my responsibility to ensure the proper functioning of all electronic equipment before my session begins.

·       I understand that I must establish a medical therapeutic relationship with my Tele-psychiatry provider in the clinic office, face-to-face, prior to commencing Tele-psychiatry treatment except in special circumstances under which I will be required to verify my identity.

·       I agree to be seen face-to-face if  recommended by my provider to maintain therapeutic services and a provider/patient relationship, unless there are circumstances that would make such a visit unsafe.

·       I consent to paying fees that are the same as an in-office visit for the type and length of service provided, by using a credit card number on file or by a check mailed at the time of service.

·       I understand that a Tele-psychiatry appointment is scheduled the same as an in-office appointment would be, and should I not be available for the appointment or cancel it less than one full business day in advance, there will be a charge for a missed appointment for the time Dr.Komrad has reserved for the scheduled appointment.