Informed Consent – Telehealth Services

This form describes S.E.M.P.É.’s Telehealth treatment and payment policies and includes:

• Your consent to receive medical treatment from S.E.M.P.É.’s and your rights with S.E.M.P.E. (listed below) and responsibilities:
  • Right To Voluntary Services;
  • Right To Refuse Services;
  • Right To Confidentiality (Privacy);
  • Right To Humane Mental And Physical Environment;
  • Right To Information;
  • Rights Pertaining To Medication; and
  • Right To Grievance Procedure;
• Your consent of the rights allotted under Telehealth Services:
• • Right To Request Special Privacy Protections;
  • Right To Request Confidential Communications;
  • Right To Inspect And Copy;
  • Right To Amend Or Supplement;
  • Right To An Accounting Of Disclosures; And
  • Right To A Paper Or Electronic Copy Of This Notice.
• Your agreement to receive services using S.E.M.P.É.’s telehealth technology; and
• Your agreement to pay in full any charges that are your responsibility.

1. I agree to receive S.E.M.P.É.’s Telehealth services. S.E.M.P.É.’s Telehealth involves the delivery of healthcare services, including assessment, treatment, diagnosis, and education, using interactive audio, video, and data communications. During my visit, S.E.M.P.É. Provider and I will be able to see and speak with each other from a remote location.

2. I understand and agree that:

• Your S.E.M.P.É. Telehealth Provider is strictly a Telehealth provider and will not meet in-person or face-to-face, unless requested under specific circumstances.
• Your provider will not be in the same location or room as my mental health counselor.
• The S.E.M.P.É. Provider is licensed in the state in which I am receiving services. I will report my location accurately during registration.
• I am a resident of Florida and will report to S.E.M.P.É. Provider with my Florida residential address and/or State Identification Card.
• I further understand that my S.E.M.P.É. Provider’s advice, recommendations, and or decisions may be based on factors not within his/her control, including incomplete or inaccurate data provided by me. I understand that my S.E.M.P.É. Provider relies on information provided by me before and during our telehealth encounter and that I must provide information about my medical history, condition(s), and current or previous medical care that is complete and accurate to the best of my ability.
• I may discuss these risks and benefits with my S.E.M.P.É. provider and will be given an opportunity to ask questions about telehealth services.
• I have the right to withdraw this consent to telehealth services
• I have the right to end the telehealth session at any time without affecting my right to present or future treatment by my S.E.M.P.É Provider.
• I understand that the level of care provided by my S.E.M.P.É. provider is to be the same level of care that is available to me through an in-person medical visit. However, if my provider believes I would be better served by face-to-face services or another form of care, I will be referred to the nearest medical center, hospital emergency department or other appropriate health care provider.
• I have the right to receive face-to-face medical services at any time by traveling to a medical center that is convenient to me.
• In case of an emergency, I will dial 911 or go directly to the nearest hospital emergency room.

3. I consent to, understand and agree that:

• I have the right to discuss the risks and benefits of all procedures and courses of treatment proposed by my healthcare provider(s), together with any available alternatives.
• S.E.M.P.É. will provide care consistent with the prevailing standards of medical practice, but makes no assurances or guarantees as to the results of treatment.
• I have the right to review and receive copies of my medical records, including all information obtained during a telehealth interaction, subject to S.E.M.P.É.’s standard policies regarding request and receipt of medical records and applicable law.
• The laws of the state of Florida will govern the procedures of payment and receipt in which S.E.M.P.É Provider will produce upon completion of services. in which I am located will apply to my receipt of telehealth services.

 

 

1. A copy of the full description of your rights will be sent prior to any healthcare services being provided. Clients are required to review and sign this document before receiving any healthcare services.

2. S.E.M.P.É. Provider is defined as any professional healthcare licensed provider or employee under the supervision of a healthcare licensed provider who provides healthcare services.