Patient Consent for Telemental Services

Informed Consent for Telemental Services

Note: This consent form provides important information about how Upstate Concierge Medicine of Colorado, PLLC, DBA, United Concierge Medicine (together with its subsidiaries, affiliates, and entities under common ownership/control) (collectively, the “Service Provider”), and their employed or contracted physicians, psychiatrists, mental health professionals, therapists, counselors, or other licensed or trained health care professionals (the “Professionals”), will provide mental and behavioral health services to you, via Telehealth*. Please review this form carefully.

*Telehealth, as used in this consent form, means the use, in accordance with applicable state law, of electronic information and communication technologies to facilitate the delivery of mental and behavioral health services which may include, but not limited to, assessment, triage, coaching, diagnosis, consultation, treatment, education, care management, referral and self-management of your care, while you and the Professionals are at different locations. Subject to applicable state law, Telehealth includes synchronous interactions and asynchronous store-and-forward transfers.


I hereby request, consent, and authorize the Service Provider and Professionals to utilize the Service Provider’s proprietary systems, methods and protocols, to provide assessment, triage, coaching, diagnosis, consultation, treatment, education, care management, referral and self-management and educate myself or those I am authorized to represent, via Telehealth (the “Services”). By signing this consent form, I am acknowledging that I have been advised of and understand the following: 

SERVICES

  1. I understand that I am responsible for any costs of any treatment, procedure, service, medicine, drug or product that may be prescribed or recommended by the Service Provider or a Professional and that is provided by other individuals or entities. I understand that I and those I am authorized to represent may receive one or more separate bills for such prescription medicines and other treatments, procedures, services or products, and I am wholly responsible for payment of such costs. I further understand that the independent entities and individuals will have their own billing and collection practices.
  2. I understand that once a Professional decides which medicines or other treatment, procedure, service or product to prescribe or recommend, if any, it is my responsibility to read and understand the risks, potential side-effects and the adverse drug interactions of the medications and any other medications I may be taking concurrently, or in consultation with my primary care or specialty physician or mental health professional regarding the same, and ultimately to determine if I accept the risks.
  3. I understand that if the person I am authorized to represent (my child/dependent) is scheduled to consult with a Professional, I may be required to be available to the Service Provider to discuss their issues.
  4. I understand that if the person I am authorized to represent is scheduled to consult with a mental health professional, I must be available to the service provider to discuss my child/dependents medication prior to a medication being prescribed. 
  5. I understand that it is my right to contact my (or my child/dependent) primary care or specialty physician or mental health professional before starting or acting on any prescription, diagnosis, recommendation or education provided by the Service Provider or a Professional, to confirm that my primary care or specialty physician, or mental health professional approves of the regimen.
  6.  Most people benefit from mental and behavioral health services. The most common benefits include improvements in overall wellbeing, self-awareness, self-esteem, self-confidence, hope, feeling understood, and relationships to other people, I understand that by receiving mental and behavioral health services, in rare instances I may experience adverse effects, The most common risks are temporary periods of emotional distress related to addressing difficult emotions, thoughts, and behaviors, and your relationship with yourself and others. I have the right to choose whether to continue receiving such services. I understand that it is my responsibility to stop any prescription medicine or other treatment, procedure, service or product prescribed or recommended by the Service Provider or Professional, and to report any adverse side-effects to the Service Provider, the Professional, my (or my child/dependent’s) primary care or specialty physician or mental health professional or go to the nearest Emergency Room if I have any reason to suspect that I have a medical emergency.
  7. I acknowledge that mental and behavioral health services carries risks, and no particular outcome is guaranteed. I understand that the Professionals will exercise reasonable judgment in providing mental and behavioral health services, but the condition with which I or the person I am authorized to represent present may worsen after the Service is provided. I further understand the Professionals may, in some cases, be limited in the Services they can provide, due to the nature of treatment via Telehealth or restrictions on Telehealth treatment under applicable state law. I acknowledge and accept these risks. 
  8. I ACKNOWLEDGE THAT IT IS MY RESPONSIBILITY TO INFORM THE SERVICE PROVIDER OR THE PROFESSIONAL OF ANY CONDITION THAT WOULD LIMIT MY ABILITY TO RECEIVE THE SERVICES PROVIDED OR THAT WOULD BE RELEVANT TO THE SERVICES THEMSELVES. IN PARTICULAR, I UNDERSTAND THAT IF I AM PLANNING TO BECOME PREGNANT, AM CURRENTLY PREGNANT, BECOME PREGNANT, OR AM BREASTFEEDING, I WILL: (A) ADVISE THE SERVICE PROVIDER AND THE PROFESSIONALS OF THIS FACT; AND (B) ASK MY OB/GYN OR PEDIATRICIAN IF THE TREATMENTS RECOMMENDED BY THE PROFESSIONALS ARE ACCEPTABLE DURING THIS PERIOD OF TIME.
  9. I understand that it is my sole responsibility to communicate and provide the Service Provider and the Professionals with detailed, accurate and complete information concerning medical, medication and other history, allergies to medications and procedures, physical, mental, and other relevant symptoms and conditions, and any other information or records requested or pertinent to the diagnosis and treatment of myself or those I am authorized to represent. I understand that, as with any service, to the extent that information is not provided or, if provided, is not detailed, accurate and complete, the Services provided by the Service Provider and the Professionals may be materially affected. I assume all risks and assume full responsibility and waive all claims against the Service Provider and the Professionals for personal injury, death, or damages of any kind, as a result of my failure to provide accurate and complete information. 

TELEHEALTH

  1. The Service Provider and Professionals will provide Services only via Telehealth. I understand that I have the option to withhold or withdraw my consent to receive the Services via Telehealth at any time, but that doing so will cause the Service Provider and the Professionals to discontinue providing subsequent Services. In such case, I understand that I will need to seek treatment and care elsewhere.
  2. I acknowledge and accept that the mental and behavioral health services, will be performed via Telehealth, in reliance upon either video, images, telephone consultation, questionnaire, health history records or otherwise. While the services will approximate, as much as possible, an appropriate in-person assessment, there are inherent risks and limitations in using Telehealth to perform it, including that the Professional may not be able to accurately evaluate or effectively treat any condition I have, which risks and limitations are not present in an in-person setting. I understand and accept these risks. 
  3. I understand the Service Provider and Professionals will strive to reduce symptoms or treat conditions with which I or the person I am authorized to represent but in some cases state law may limit the ability of a Professional to prescribe certain medications via Telehealth, without performing a prior in-person examination and/or assessments, the care may be limited. I also understand that, due to a specific l conditions or technical problems, a face-to-face consultation may be necessary after the services are provided. I acknowledge that, in these cases, a Professional may recommend that I seek in-person treatment and a referral will be made to outside entity. It is my responsibility to decide whether to accept and follow through with the referral.  
  4. I understand that federal and state laws concerning the confidentiality of health information, including patient access and amendments to medical records, apply to Services delivered and information acquired via Telehealth, including mental health Services. I acknowledge that in rare circumstances, security safeguards and protocols could fail, causing a breach of patient privacy.
  5. I understand that technical difficulties, such as service interruptions, may occur during a Telehealth encounter. If I am unable to reconnect with the Professional within ten (10) minutes of an interruption, I may be required to reschedule the Telehealth encounter or I will work with the Professional to identify an alternative communication method if the technology tool fails. The most reliable backup is a phone.  

  1. I understand that if I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms, or experiencing a mental health crisis, I should immediately call 911 or go to the nearest emergency room. If the Service Provider or a Professional determines that I may need a higher level or care or that remote treatment is not appropriate, I will be recommended and/or referred to a higher level of care. 

I hereby represent that I have read and fully understood and agreed to:  (i)[Link to: UCM HIPAA Notice of Privacy Practices] the Notice of Privacy Practices; (ii) [Link to: UCM  Healthcare Privacy Policy]the Website Privacy Policy; and (iii) [Link to: UCM Terms of Use] the Website Terms of Use. 

By electronically signing this form, I acknowledge and agree to all of the above. I am further agreeing to conduct transactions electronically and intend for my electronic signature to be binding on myself and, if applicable, the person I am authorized to represent. I understand that I will receive a digital copy of this Agreement concurrently upon execution to print and/or retain.

By electronically signing this form, I assert that:

  • I am of legal age to request the services and consent hereto, or I am the parent, legal guardian, or person acting in loco parentis of the individual who will receive the Services.
  • I have read, or had read to me, and understand the above information.
  • The decision to consent to, or to refuse, the Services is voluntary and entirely mine.
  • I have had the opportunity to discuss the Services, including the purposes, limitations, and possible risks, with the Service Provider or Professional.
  • I have all the information desired, and all my questions have been satisfactorily answered.

Revised/Reviewed: November 1st, 2022