Teletherapy Informed Consent
Teletherapy involves the real-time provision of behavioral therapy services using advanced telecommunication technology, which includes interactive audio, video, or other electronic media. The use of teletherapy technology allows Marvin Behavioral Health., Inc. (“Marvin Behavioral”) and its therapists to see and communicate with you in real-time from a remote or distant location.
You understand that you will not be in the same location as your therapist and that the videoconferencing technology will not be the same as a direct patient/therapist visit due to the fact that you will not be in the same room as your therapist. An alternative to this teletherapy is a direct in-person session with a therapist. You understand that your therapist does not offer direct in-person sessions, but that he or she will refer you to a therapist who provides direct in-person sessions if you so request.
You voluntarily request and consent to Marvin Behavioral psychiatrists, psychologists, LICSWs/ LCSWs, LMFTs, and LPCs (“therapists”) assigned by Marvin Behavioral conducting your therapy sessions by utilizing teletherapy services. You may request a different therapist if you are not satisfied with the services provided by your assigned therapist. You understand that your therapist will provide a remote teletherapy session using HIPAA-compliant interactive videoconferencing technology where your therapist and you can see and hear each other in real time, even though you are in different locations. You may also contact and communicate with your therapist by messaging your therapist through the Marvin technology platform and by telephone.
You understand that your Therapist will not prescribe medication.
You understand that your therapist or you can discontinue the teletherapy session if either one of you feels that the videoconferencing connections are not adequate for the situation. In this situation, you can request a referral for in-person services. You understand that an in-person referral may require you to pay a fee to your new therapist.
You understand that you must provide written or verbal consent to allow any other individual (besides your therapist or your therapist’s supervisor) to be present during a teletherapy visit
You understand that you must provide information about your medical history, condition(s), and current or previous therapy or counseling care that is complete and accurate to the best of your knowledge and ability.
You understand that the level of care provided by your therapist is to be the same level of care that is available to you through an in-person therapy session.
You acknowledge that you have been given a copy of Marvin Behavioral’s Notice of Privacy Practices and are encouraged to review this Notice prior to any therapy sessions.
You acknowledge that your therapist has provided you with notice of how you may file a complaint with your therapist’s licensing board of the state where you are located, relating to the provision of any teletherapy services.
You understand that you have a right to confidentiality of your therapy under the same laws that protect the confidentiality of your therapy records for in-person therapy services. Any information that you disclose to your therapist during your therapy session generally is confidential. However, there are exceptions to confidentiality, including mandatory reporting of child or elder abuse, or any threats of violence you may make towards yourself or a reasonably identifiable person.
You also understand that your therapist may share your therapy information with Marvin, Inc. (“Marvin”), employees of Marvin, and other Marvin Behavioral Therapists for administrative and therapy services. These individuals will ensure that your therapy information is kept confidential. You may request copies of therapy information that Marvin maintains about you by emailing Marvin. You may also ask your therapist for a copy of therapy information that your therapist maintains about you.
You acknowledge receiving a copy of the Notice of Privacy Practices for Marvin Behavioral that provides a complete description of the uses and disclosures of your Protected Health Information (“PHI”). You have had an opportunity to review this information before signing this form, and you consent to Marvin Behavioral releasing your PHI to carry out treatment, payment or health care operations.
You hereby assign all of your rights and claims for payment by Medicare, Medicaid, and other third-party insurance carriers to Marvin Behavioral for services that you receive from Marvin Behavioral, and you request that payment of Medicare, Medicaid, or third-party insurance benefits be made on your behalf to Marvin Behavioral. You also authorize Marvin Behavioral to release information about services that you receive from Marvin Behavioral to Medicare, Medicaid, and third-party insurance companies or their agents as needed to determine benefits to which you are entitled for the services provided. You acknowledge that you must notify Marvin Behavioral as soon as possible of any changes to your insurance coverage and that failing to do so may result in unpaid claims that you will be responsible for paying.
You understand that your therapist will ask for your physical location at the start of every teletherapy session to ensure that you are matched with a therapist who is licensed in the state where you are located.
YOU ACKNOWLEDGE THAT IF YOU ARE IN NEED OF MEDICAL TREATMENT OR EMERGENCY CARE, THAT YOU SHOULD IMMEDIATELY CONTACT YOUR HEALTHCARE PROVIDER OR CALL 911. If your therapist believes that you might harm yourself or another person or if you have a medical emergency, you understand that your therapist may contact 911, emergency medical services, a hospital near where you are located, or a support person that you have identified to Marvin Behavioral.
You understand that there are potential risks to this technology, including interruptions, unauthorized access (even though the videoconferencing technology is encrypted), and technical difficulties. You understand that in the event of a technical interruption in service, you will reach out to email@example.com for troubleshooting assistance and, when necessary, reschedule your session.
THE INFORMATION PROVIDED BY YOUR THERAPIST IS NOT INTENDED TO BE A SUBSTITUTE FOR PROFESSIONAL MEDICAL ADVICE, DIAGNOSIS OR TREATMENT THAT CAN BE PROVIDED BY MY DOCTOR, OR OTHER MEDICAL OR CLINICAL HEALTHCARE PROFESSIONAL.
Based on the above, you believe that you have sufficient information to give this informed consent for the provision of teletherapy services by Marvin Behavioral therapists.
By clicking on the “I Agree” box, you certify:
That you have read or had this form read and/or had the form explained to you.
That you fully understand its contents, including the risks and benefits of teletherapy services.
That you have been given the opportunity to ask questions, and that your questions have been answered to your satisfaction.
That you hereby consent to teletherapy as an acceptable form of delivering therapy services to you and that this consent will cover any and all of your sessions using teletherapy. You understand that you may withdraw your consent to teletherapy services by providing written notification to firstname.lastname@example.org.