Consent for Telehealth

Telehealth involves the use of electronic communications to enable providers at different locations to share individual Participant information for the purpose of improving Participant care. Providers may include primary care practitioners, specialists, and/or sub specialists. The information may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:

• Participant health records
• Live two-way audio and video
• Output data from health devices and sound and video files

Electronic systems used will incorporate network and software security protocols to protect the confidentiality of Participant identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

This Informed Consent for Telehealth contains important information focusing on providing healthcare services virtually. Please read this carefully, proceeding with registration and signing this document, it will represent an agreement between you and Synchronous Health, Inc.

Benefits and Risks of Telehealth

Telehealth refers to providing counseling, coaching, consulting, or other Synchronous Health Inc. services remotely using telecommunications technologies, such as video conferencing or telephone.

One of the benefits of telehealth is that the patient and clinician can engage in services without being in the same physical location. This can be helpful particularly during the Coronavirus (COVID-19) pandemic in ensuring continuity of care as the patient and clinician likely are in different locations or are otherwise unable to continue to meet in person. It is also more convenient and takes less time. Telehealth, however, requires technical competence on both parts to be helpful. Although there are benefits of telehealth, there are some differences between in-person treatment and telehealth, as well as some risks. For example:

• Risks to confidentiality. As telehealth sessions take place remotely, there is potential for other people to overhear sessions if you are not in a private place during the session. On our end, we will take reasonable steps to ensure your privacy. It is important however, for you to make sure you find a private place for our session where you will not be interrupted. It is also important for you to protect the privacy of our session on your cell phone or other device. You should participate in therapy only while in a room or area where other people are not present and cannot overhear the conversation.

• Issues related to technology. There are many ways that technology issues might impact telehealth. For example, technology may stop working during a session, other people might be able to get access to our private conversation, or stored data could be accessed by unauthorized people or companies.

• Crisis management and intervention. Usually, we will not engage in telehealth with Participants who are currently in a crisis situation requiring high levels of support and intervention. We may not have an option of in-person services presently, but in a crisis situation, you may require a higher level of services. Before engaging in telehealth, we will develop an emergency response plan to address potential crisis situations that may arise during the course of our telehealth work.

Informed Consent

For Counseling, Coaching, Consulting or other Synchronous Health Services

The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect. This consent will provide a clear framework for counseling, coaching, and consulting services.

By accepting, you acknowledge that you understand the following:

1. I understand that the laws that protect privacy and the confidentiality of health information also apply to telehealth, and that no information obtained in the use of telehealth which identifies me will be disclosed to researchers or other entities without my consent.
2. 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.
3. I understand that I have the right to inspect all information obtained and recorded in the course of a telehealth interaction, and may receive copies of this information for a reasonable fee.

CONSENT FOR TELEHEALTH COUNSELING, COACHING, OR CONSULTATION

1. I understand that I am choosing a health care provider with Synchronous Health Inc., to engage in telehealth services.
2. I understand that this provider will need to verify my identity and state of residence and will do so by asking me to show a government issued identification card.
3. This 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 Participant/health care provider visit due to the fact that I will not be in the same room as my provider.
4. I understand that telehealth has potential benefits including easier access to care and the convenience of meeting from a location of my choosing.
5. I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.
6. I know where the nearest emergency room is, I have the crisis phone number, and I am willing to access these services if I become triggered during a session and my provider does not have direct access to me due to geography.

Confidentiality

The session content and all relevant materials to the Participant’s treatment will be held confidential unless the Participant requests in writing to have all or portions of such content released to a specifically named person/persons. Limitations of such Participant held privilege of confidentiality exist and are itemized below:

1. Risk of bodily harm to self or others, including children or elderly persons.
2. Suspicion of child abuse or elder abuse including emotional, physical, sexual abuse and neglect.
3. If a court of law issues a legitimate subpoena for information stated on the subpoena.
4. Third party payers (insurance companies) request dates of service, diagnoses, and treatment progress.

Occasionally we may need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information about you may be shared in this context without using your name.

1. Click here for our privacy policy: https://sync.health/privacy-policy
2. Click here for our terms of use: https://sync.health/terms-of-use