Telehealth is the delivery of medical or mental health services using interactive video conferencing or a telephone call (when permitted), that enables a provider at a distant location to provide treatment to me. I understand that this consultation will not be the same as a direct in office visit. Telehealth will allow me to receive medical care without the need to visit the office and travel long distances. I understand that my insurance may not cover telehealth services. If my insurance does not cover telehealth services, I agree that I will be responsible for self-pay charges for the visit. I am aware that during my telehealth appointment, it is important to be in a private location for the duration of the appointment. I acknowledge that the telehealth sessions will not be recorded by either party. In the event of a transmission failure, I am aware of the contingency plan. I am aware that I can refuse services via telehealth and that such refusal will not be used as a basis to limit access to other available services. Alternatives to telehealth services may possibly cause delays in service/s due to scheduling issues, need to travel, and/or risks associated with not having the services provided by telehealth. The interactive electronic systems used in telehealth are known to incorporate network and software security protocols to protect the confidentiality of information and audio/visual data. These protocols include measures to safeguard the data and to aid in protecting against intentional or unintentional corruption. Our practice currently uses HIPAA compliant telehealth platforms. We may use the landline telephone for audio to enhance the security of the information being discussed.
During the telehealth consultation -
- Details of my medical history, current medications, and results of medical tests will be discussed.
- Non-medical personnel may be present to assist in operating conferencing equipment, if needed.
- At times students may be present during the session. I will be informed about who is present in the office.
Potential benefits:
- Patient convenience
- Increased accessibility to psychiatric care
Potential Risks:
As with any medical procedure, there may be potential risks associated with the use of telehealth. These risks include, but may not be limited to:
- The information transmitted may not be sufficient (e.g., poor resolution) to allow for appropriate medical decision making by your provider.
- Your provider may not be able to provide treatment to me using interactive Audio-Video equipment nor provide for or arrange for emergency care that I may require.
- Delays in medical evaluation and treatment may occur due to deficiencies or failures of the equipment.
- Security protocols can fail, causing a breach of privacy of my confidential medical information.
- A lack of access to all the information that might be available in a face-to-face visit but not in a telehealth session may result in errors in medical judgment.
Alternatives to the use of telehealth:
- Traditional face-to-face sessions in the office
My Rights:
- I understand that the laws that protect the privacy and confidentiality of medical information also apply to telehealth.
- I understand that the technology used by the providers is encrypted to prevent unauthorized access to my private medical information.
- I have the right to withhold or withdraw my consent to the use of telehealth during my care at any time. I understand that my withdrawal of consent will not affect any future care or treatment.
- I understand that my providers have the right to withhold or withdraw approval for the use of telehealth during my care at any time.
- I understand that all rules and regulations which apply to the practice of medicine in the state of Pennsylvania also apply to telehealth services.
My Responsibilities:
- I will not record any telehealth sessions without written consent from Dr. Kant or his associates. I understand that my providers will not record any of our telehealth sessions without my written consent.
- I will inform my providers if any other person can hear or see any part of our session before the session begins. My providers will inform me if any other person can hear or see any part of our session.
- I understand that I, not my providers, am responsible for configuring all equipment used on my computer for telehealth. It is my responsibility to ensure the proper functioning of all equipment before my session begins.
- I must be a resident of the state of Pennsylvania or any other state where Dr. Kant holds a valid medical license to be eligible for telehealth services from my providers.
- I understand that my initial evaluation may not be done by telehealth except in special circumstances under which I will be required to verify my identity to provider satisfaction before the evaluation.
Telehealth Video Instructions:
- Log into your MYIO Patient Portal Account via the app or this link https://valant.io/myio/RaviKantMDPC
- Click on your appointment and click "Check-In". Click "I'm ready, check me in"
- Click on the "Join Now" button to begin your telehealth session.
I have read and understand the information provided above regarding telehealth, I have discussed it with Dr. Kant or his associates, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telehealth for my medical care and authorize Dr. Kant or his associates to use telemedicine in the course of my evaluation, diagnosis and treatment. If for any reason/s, telehealth is not considered appropriate for my treatment by my provider/s, then I will need to come to the office for ongoing treatments.
