Telepsychiatry Consent

Is the patient under the age of 18?

Yes No

Telepsychiatry is a form of telemedicine that allows patients to access psychiatric care using an audio-video interface. BMC utilizes Doxy.me, which is a HIPAA-compliant telemedicine platform.

Benefits of Telemedicine:

Improved access to psychiatric care by enabling a patient to remain in his/her home or office.

More efficient psychiatric evaluation and management.

Maintaining treatment schedule despite logistical obstacles.

Possible Risks of Telemedicine:

As with any medical procedure, there are potential risks associated with the use of telepsychiatry. These risks include, but may not be limited to:

-In rare cases, information transmitted may be poor resolution, which may make the video portion of the visit of lesser quality

-In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information.

By signing this form, I understand the following:

I understand that the laws that protect privacy and the confidentiality of medical information also apply to telepsychiatry, and that no information obtained in the use of telepsychiatry which identifies me will be disclosed to researchers or other entities without my consent.
I understand that I have the right to withhold or withdraw my consent to the use of telepsychiatry in the course of my care at any time, without affecting my right to future care or treatment.
I understand that a variety of alternative methods of psychiatric care may be available to me, and that I may choose one or more of these at any time.

Billing of Telehealth Services:

I understand that if possible, BMC will bill my telehealth visits to my insurance company. I understand that I am responsible for any applicable deductible, co-insurance or co-pays, or for the cost of the session if it is not covered by my insurance. I also understand that the BMC Payment Policy also applies to telehealth services.

Patient Consent To The Use of Telepsychiatry

I have read and understand the information provided above regarding telepsychiatry, have discussed any questions with BMC staff (if necessary), and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telepsychiatry for my care at the Behavioral Medical Center – Troy.

Patient first name

Patient last name

Birthdate

Name of Parent/Guardian if patient is a minor

Patient or Parent/Guardian Signature

Date: