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APN Connection Informed Consent for Telehealth

INFORMED CONSENT FOR THE USE OF TELEHEALTH SERVICES

Welcome to All Points North Lodge. This document contains important information about our telehealth services. Please read it carefully in order to provide your consent for evaluation and treatment via telehealth. You are encouraged to ask any questions you might have while you are reviewing this document and at any other time.

All Points North Lodge

The Vision of All Points North Lodge is to establish wholeness, restoration and wellness as an attainable goal for every person, family, and the community where we are privileged to serve. Wholeness, restoration and wellness are the foundational concepts of our work. All Points North Lodge embraces the holistic view that people are created and exist within a bio-psycho-social-spiritual framework.

What is telehealth?

Telehealth means the delivery of health care services through the use of interactive electronic and telecommunication technologies between a provider in one location and a patient in another location. 

When and how will telehealth services be provided to me?

Telehealth may be used to provide behavioral health services to you when you are a client onsite with All Points North or offsite for Intensive Outpatient and Outpatient services. This means that a behavioral telehealth provider will be interacting with you by video over the computer instead of in person. You will be able to speak with the provider and ask any questions during your visit. The provider will be able to assess your medical condition and prescribe treatment, as appropriate.

STANDARD OF CARE:  Health care providers who use telehealth must adhere to the requirements and restrictions of their applicable licensure. Your telehealth provider will follow evidence-based guidelines and all state and federal regulations.

CONFIDENTIALITY:  Your telehealth visits will take place in a private area. Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with the telehealth services. 

MEDICAL RECORDS:  All telehealth services will be documented in your medical record and will remain private and confidential as required by applicable law.

COORDINATION OF CARE:  During the course of treatment, your telehealth provider will coordinate care with the All Points North Lodge and APN Connection teams and, with your permission or at your direction, your other health care providers, and may refer you for an in-person treatment, if necessary.

POSSIBLE RISKS:  As with any in person health care encounter, there are potential risks associated with the use of telehealth.  These risks may include, but are not limited to:

  • Limitations on the availability and/or appropriateness of specific behavioral or mental telehealth services that may be hindered as a result of the services being offered remotely.
  • Confidentiality and security of your information through use of unsecure electronic and telecommunication technologies.
  • Technological issues during your telehealth visit.  Alternative means of communication will be provided if connection is lost.

Consent

I have read the above information and have had an opportunity to ask questions. I understand the benefits and risks of receiving behavioral telehealth services.  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 consent to the use of behavioral or mental telehealth services.
  • I do not consent the use of behavioral or mental telehealth services.

Reason (optional): ___________________________________________________________

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