Telehealth Consent

Telehealth services provided by The Guidance Center will utilize HIPAA compliant real time, two-way interactive audio-video transmission.

Electronic systems used will incorporate network and software security protocols to protect the confidentiality of client identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

Expected Benefits:

  • Increased access for those who may be challenged by geographic location, transportation, and/or other barriers

Possible Risks:

  • Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment and technologies.
  • In rare events, the provider may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled telehealth consult or an in-person meeting with your provider.
  • In very rare events, security protocols could fail, causing a breach of privacy of personal medical information.

After reading this, you will be asked to indicate (by clicking the terms of service link before you enter the waiting room) that you understand and agree to the following:

  1. Telehealth involves the use of an encrypted real time HIPAA compliant audio/video platform (or via telephone under certain circumstances) to communicate with my clinician.
  2. I hereby consent to receiving services via telehealth. I understand it is up
    to The Guidance Center to determine whether or not my needs are appropriate for telehealth taking into consideration my preferences when making determinations.
  3. The laws that protect the confidentiality of my medical information in face-face visits or sessions also apply to telehealth visits. I understand that the information disclosed by me during the course of my visit or therapy session is generally confidential. However, the mandatory reporting exceptions to confidentiality that apply in face-to-face sessions also apply to telehealth.
  4. If during a telehealth visit, my provider or therapist suspects that I am at imminent risk for harming myself or others, my provider or therapist is required by law to contact the authorities to ensure safety for myself and others.
  5. I understand there is a risk of technical failures during the telehealth encounter beyond the control of The Guidance Center. I agree to hold harmless The Guidance Center for delays in evaluation or for information lost due to such technical failures.
  6. I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment. I understand that I may suspend or terminate access to the service at any time for any reason or for no reason.
  7. I understand that if I am experiencing an emergency, that I will be directed to dial 9-1-1 immediately and that The Guidance Center staff will also attempt to connect me directly to any local emergency services.
  8. I understand the alternatives to telehealth, such as in-person services are available to me, and in choosing to participate in a telehealth consultation, I understand that some parts of the services involving physical tests may be conducted at the direction of the clinician.
  9. I understand that visits/sessions may also be monitored for training, audit, support, or other reasons associated with my care.
  10. I understand that I may expect the anticipated benefits from the use of telehealth in my care, but that no results can be guaranteed or assured.
  11. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Persons may be present during the consultation other than The Guidance Center clinician in order to operate the telehealth technologies. I further understand that I will be informed of their presence in the appointment and thus will have the right to request the following: (1) omit specific details of my
    history/assessment that are personally sensitive to me; (2) ask non-trained personnel to leave the telehealth appointment; and/or (3) terminate the consultation at any time.
  12. If applicable, I understand that any controlled substances are prescribed at the sole discretion of the provider in compliance with federal and state regulations. There is no guarantee that I will be given a prescription at all.
  13. The Guidance Center may require an in-person visit from time to time to continue to prescribe medications or to provide treatment.
  14. I understand that if I participate in an appointment, that I have the right to request a copy of my medical records which will be provided to me at reasonable cost of preparation, shipping, and delivery.
  15. I understand that in the event of any problem with the website or related services, I agree that my sole remedy is to cease using the website or terminate access to the service. Under no circumstances will The Guidance Center be liable in any way for the use of the telehealth services, including but not limited to, any errors or omissions in content or infringement by any content on the website of any intellectual property rights or other rights of third parties, or for any losses or damages of any kind arising directly or indirectly out of the use of, inability to use, or the results of use of the website, and any website linked to the website, or the materials or information contained on any or all such websites. I agree that I will not hold The Guidance Center, its subsidiaries or affiliates liable for any punitive, exemplary, consequential, incidental, indirect or special damages (including, without limitation, any personal injury, lost profits, business interruption, loss of programs or other data on my computer or otherwise) arising from or in connection with your use of the website whether under a theory of breach of contract, negligence, strict liability, malpractice or otherwise, even if we or they have been advised of the possibility of such damages.
  16. I understand that The Guidance Center makes no representation that materials on this website are appropriate or available for use in any other location. I understand that if I access these services from a location outside of the United States, that I do so at my own risk and initiative and that I am ultimately responsible for compliance with any laws or regulations associated with my use.
  17. All The Guidance Center policies and procedures, risks and benefits noted in other places still apply to services provided via telehealth. This includes but is not limited to payment. Being that services are provided to you outside of our facilities, you are responsible for privacy in the environment for which you are in during a telehealth you can expect that your service is provided in a private location by your provider. I further understand that my provider may also elect to reschedule the visit or session.
  18. My insurance will be billed as it is during face-to-face visits or sessions. Any co-payments associated with my insurance will be billed to me. If my insurance is found to be inactive or does not cover telehealth, I am fully financially responsible for the expenses of the visit or session
  19. I consent to photographs, digital or audio recordings, and/or images of me being recorded for patient care, security purposes and/or the  agency operations purposes (e.g., quality improvement activities). I understand that the practice/clinic retains the ownership rights to the images and/or recordings. I will be allowed to request access to or copies of the images and/or recordings when technologically feasible unless otherwise prohibited by law. I understand that these images and/or recordings will be securely stored and protected. Images and/or recordings in which I am identified will not be released and/or used outside the facility without a specific written authorization from me or my legal representative unless otherwise permitted or required by law.


Client Consent
By clicking the terms of service link before you enter the waiting room you agree that you have read this document carefully and understand the risks and benefits of telehealth and have had your questions explained and hereby give informed consent to participate in telehealth under the terms described herein.