Consent for Telehealth Consultation

1. I understand that my health care provider wishes me to engage in a telehealth consultation.

2. My health care provider explained to me how the video conferencing technology that will be used to affect such a consultation will not be the same as a direct client/health care provider visit due to the fact that I will not be in the same room as my provider.

3. I understand that a telehealth consultation has potential benefits including easier access to care and the convenience of meeting from a location of my choosing.

4. I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.

5. I have had a direct conversation with my provider, during which I had the opportunity to ask questions in regard to this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand. Consent to use Doxy.me, ZocDoc, Zoom Services Doxy.me, ZocDoc and Zoom are the technology services we might use to conduct telehealth videoconferencing appointments.

By agreeing to this document, I acknowledge:

1. Doxy.me and ZocDoc provide HIPAA compliant video telehealth platforms. If neither of these are functioning optimally, we may choose to use the Zoom platform. The Zoom configuration used by Nathaniel Smith, LCSW-R is not HIPAA compliant and therefore the use of Zoom entails the undertaking of risks associated with non-HIPAA compliant service. HIPAA is the Health Insurance Portability and Accountability Act of 1996 intended to help protect confidentiality of health information among other goals.

2. Doxy.me, ZocDoc and Zoom are NOT Emergency Services and in the event of an emergency, I will use a phone to call 911.

3. Though my provider and I may be in direct, virtual contact through the Telehealth Service, neither Doxy.me, ZocDoc nor Zoom provide any medical or healthcare services or advice including, but not limited to, emergency or urgent medical services.

4. The Doxy.me, ZocDoc and Zoom services facilitate videoconferencing and are not responsible for the delivery of any healthcare, medical advice or care.

5. I do not assume that my provider has access to any or all of the technical information in the Doxy.me, ZocDoc and Zoom services – or that such information is current, accurate or up-todate. I will not rely on my health care provider to have any of the information on the Doxy.me, ZocDoc and Zoom services.

6. To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment.

By indicating I am in agreement with this form on the separate agreement form, I certify:

● That I have read or had this form read and/or had this form explained to me

● That I fully understand its contents including the risks and benefits of the procedure(s).

● That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.