Tele-Medicine/Tele-Health Informed Consent

I, the client named above, hereby consent to engaging in telemedicine at New Directions Northwest, Inc. (NDN) as part of my mental health psychotherapy or addictions treatment. I understand that ‘telemedicine’ includes the practice of health care delivery, assessment, diagnosis, consultation, treatment, transfer of medical data, and psychoeducation using interactive audio, video, or data communications. I understand that, with my signed consent, telemedicine may also involve the communication of my mental health and addiction information, both orally and visually, to other health care practitioners within NDN.

Technology: I understand that I will need to download an application and/or software to use the Zoom platform. I also need to have a broadband Internet connection or a smart phone device with a good cellular connection at home or at the location deemed appropriate for services. I also understand that in case of technology failure, I may contact NDN via phone to coordinate alternative methods of treatment.

Clients using insurance: I am responsible for contacting my insurance company, if applicable, to determine what my out-of-pocket costs may be. I authorize insurance benefits to be paid directly to NDN and that NDN may release any information to my insurance provider required for processing my claims.

I understand that using the Telemedicine platform allows access to mental health and addiction services that might not otherwise be available to me due to my mental health, addiction, and /or my physical, resource, or geographic limitations, or current public health concerns that exist within our community.

Scheduling: I understand that scheduling is conducted through NDN and is based on my provider’s normal clinic hours. Telemedicine appointments are considered outpatient services and not intended as a substitute for emergency or crisis services. Crisis or mental health emergencies should be directed to the NDN Crisis Line at: (541) 519-7126.

Video/Audio Recording: As a general practice NDN DOES NOT record Telemedicine sessions without prior permission.

Confidentiality: The laws that protect the confidentiality of my medical information also apply to telemedicine. As such, I understand that the information disclosed by me during the course of my therapy is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality including, but not limited to: reporting child, elder, and dependent adult abuse; expressed threat of violence towards an ascertainable victim; and where I made my mental or emotional state an issue in a legal proceeding. NDN’s Telemedicine platform is HIPAA compliant to protect my privacy and confidentiality.

I understand that I have the following rights with respect to telemedicine:
1. I have the right to withdraw my consent at any time.

2. I understand that there are risks and consequences associated with telemedicine including, but not limited to the possibility, despite reasonable efforts on the part of my counselor/therapist/clinical intern, that the transmission of my medical information could be disrupted or distorted by technical failures. In addition, I understand that telemedicine-based services and care may not be as complete as face-to-face services. I also understand that if my counselor/therapist/clinical intern believes I would be better served by another form of psychotherapeutic services (e.g. face-to-face services) I will be referred to a counselor/therapist who can provide such services in my geographic area.

3. I understand that I may benefit from telemedicine but that results cannot be guaranteed or assured.

4. I understand that NDN may not provide telemedicine services to me if I am outside of the State of Oregon and I understand that I may access telemedicine services from NDN from within the State of Oregon only.

5. I understand that I have a right to access my mental health information and copies of medical records in accordance with Oregon state law.