Consenting to Telehealth Therapy

All clients who have chosen to conduct their therapy via telehealth with our providers are required to sign a consent to acknowledge the following details, provided in their registration packet.

 

By choosing to facilitate your own, or your child(rens) counseling sessions via telehealth using a HIPAA compliant program with a therapist through “Tranquil Solutions for a Centered Mind, LLC” as part of your/your child’s therapeutic process you have agreed and understand that:

 

Telehealth video conferencing technology will not be the same as a direct patient/therapist visit due to the fact that I will not be in the same room as my therapist.

I am to be online at least five minutes prior to the session, alone, in a quiet room, door closed. I can check in to the virtual waiting room of my therapist; in turn, my therapist will be promptly notified. My therapist will start our telehealth session within 5 minutes of our scheduled appointment time.

If others are present during the session other than myself and my therapist, they will maintain the confidentiality of the information obtained. I further understand that I will inform, or be informed, of their presence in the session and thus either party will have the right to request the following: (1) omit specific details of my medical history/physical examination that are personally sensitive to me; (2) ask them to leave the room: and/or (3) terminate the session at any time.

The alternatives to a telehealth session are in-office sessions and I have chosen to participate in telehealth sessions when in-office sessions cannot be arranged due to scheduling conflicts.

 

Also, understand the following limitations of telehealth video therapy sessions:

​

Confidentiality should be treated like an in-office session: no outside distractions, turn off cell phones, maintain visual contact the entire time, close other programs on the computer and I will not be late.

The telehealth platform used implements state-of-the-art security and encryption protocols to assure that data integrity and privacy is maintained. As a result, the practices telehealth service complies with HIPAA, GDPR, PHIPA/PIPEDA, & HITECH requirements.

The practices telehealth services work best with Chrome, Safari, Firefox, and is accessible from desktop, tablet, and smartphone [Android & iOS].

That there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my therapist or I can discontinue the telehealth visit if it is felt that the videoconferencing connections are not adequate for the situation.

 

Also, understand the following financial factors associated with my telehealth sessions:

 

Tranquil Solutions for a Centered Mind, LLC will submit billing to my insurance(s) for payment of my telehealth therapy sessions. And I understand that I am fully responsible for the cost of the services, as outlined by my insurance policy. I will remit payment for services either online, prior to my session, and/or provide your credit card information to be kept on file for payment processing to be done after sessions, in the event of deductible or coinsurances are applicable with my insurance policy.

Telehealth sessions are only billable to insurance(s) when both parties are within Delaware limits according to their originating locations (addresses on file with insurance). Or in cases of prior authorization approval or pandemic amendments.

I understand that I must cancel my scheduled telehealth session with at least 24 hours’ notice, the same as any other appointment. And that I am responsible for paying for any missed or late-canceled telehealth session in full, as outlined by the practice policy, before rescheduling my session.