Before you take part in a telehealth video counseling session, you should understand what to expect and what the risks and benefits can be.
Feel free to review these documents:
Read and sign this consent form using the signature space at the bottom of the page. Upon completion you will be able to schedule video counseling.
Definition of Telehealth
Telehealth involves the use of electronic communications to enable Prestige Healthcare Resources Inc. DBA Prestige Behavioral Health’s mental health professionals to connect with individuals using interactive video and audio communications.
Telehealth includes the practice of psychological health care delivery, diagnosis, consultation, treatment, referral to resources, education, and the transfer of medical and clinical data.
I understand that I have the rights with respect to telehealth:
Payment for Telehealth Services
Prestige Behavioral Health will bill Medicaid, Medicare or MCOs for telehealth services. If insurance does not cover telehealth, the individual will pay out-of-pocket and we will provide you with a statement of service.
Patient Consent to the Use of Telehealth
I have read and understand the information provided above regarding telehealth, have discussed it with my counselor, and all of my questions have been answered to my satisfaction. I have read this document carefully and understand the risks and benefits related to the use of telehealth services and have had my questions regarding the procedure explained. I hereby give my informed consent to participate in the use of telehealth services for treatment under the terms described herein. >By my signature below, I hereby state that I have read, understood, and agree to the terms of Informed Consent and HIPPA Privacy Practice Notice.
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I have read, understood, and agree to the terms of the Informed Consent.*
I have read, understood, and agree to the HIPPA Privacy Practice Notice.
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