TELEHEALTH AND INFORMED CONSENT FOR BEHAVIORAL HEALTH
DO NOT USE THIS SERVICE FOR EMERGENCY MEDICAL CONDITIONS OR NEEDS. IF YOU ARE CURRENTLY EXPERIENCING A MENTAL HEALTH OR OTHER MEDICAL EMERGENCY, IMMEDIATELY CALL 911.
If you are considering suicide or thinking about taking an action that may cause harm or danger to you or to others, you must immediately call 911. If you are considering suicide, we urge you to call the National Suicide Prevention Hotline at 1-800-273-TALK (8255). Please also see Support Resources for additional support.
Only use our service if you’ve read this information and subsequently made an informed decision that our service is right for you. If you have any questions, please send us a message through the ravkoo Health App or at email@example.com.
By signing and/or opting to agree to this form, I understand and agree with the following:
Telehealth/Telemedicine (“telehealth”) involves the use of electronic communications to enable Authorized Providers at different locations to share individual patient medical information for the purpose of improving patient care. I consent to receive behavioral health treatment via telehealth from ravkoo Health Authorized Providers. Authorized Providers may include independently licensed mental health providers and psychiatric medical providers.
Telehealth/Telemedicine requires transmission, via Internet or tele-communication device, of health information, which may include:
- Progress reports, assessments, or other intervention-related documents; and
- Videos, pictures, text messages, audio and any digital form of data
Your participation in clinical services provided through ravkoo Health including appointments, content of counseling sessions, and health records, are confidential as outlined by federal and state law. Communication between you and an Authorized Provider may only be disclosed if:
- the Registered User/Client signs a Release of Information form authorizing such disclosure to a named third party,
- there is a determination of immediate danger of serious harm to the client or someone else, or
- there is a determination of abuse of a vulnerable population or improper behavior by a medical professional in accordance with state and federal laws.
I understand that I must check the App or Website for messages because this is the way that the Authorized Provider will communicate important information to me. I understand that if I do not check the App regularly, then my care may be delayed.
I understand that if I have any questions relating to my care that are not urgent, I can message the Authorized Provider through the App. I understand that the Authorized Provider may not review and respond to my messages until the next business day depending on when the message was sent.
Telehealth sessions may not always be possible. Disruptions of signals or problems with the Internet’s infrastructure may cause broadcast and reception problems (e.g., poor picture or sound quality, dropped connections, audio interference) that prevent effective interaction between the Authorized Provider, participant, patient or care team.
I hereby release and hold harmless ravkoo Health and all members of my care team from any loss of data or information due to technical failures associated with the telehealth service. I understand and agree that the health information I provide at the time of my telehealth service may be the only source of health information used by the Authorized Provider during the course of my evaluation and treatment at the time of my telehealth visit, and that such Authorized Provider may not have access to my full medical record or information.
I understand that I will be given information about test(s), treatments(s) and procedures(s), as applicable, including the benefits, risks, possible problems or complications, and alternate choices for my medical care through the telehealth visit.
I have the right to withhold or withdraw consent to the use of telehealth services at any time and revert back to traditional in-person clinic services. I understand that if I withdraw my consent for telehealth, it will not affect any future services or care benefits to which I am entitled.
I hereby consent to the use of telehealth in the provision of care and the above terms and conditions.