Consent for Telehealth Treatment

Due to current restrictions in place because of the COVID-19 pandemic, and for the protection of patients and staff, the Health Center at Auraria will provide assessment and treatment via videoconferencing with our mental health and medical providers.
As a current or prospective client who wishes to use telehealth services, I agree to the following:
Location & Access: The personnel providing telehealth are at a location different than I. I agree to let my provider know the state/location from which I am currently conducting the telehealth visit. To ensure quality and privacy, the Health Center will use the Microsoft Teams application to conduct telehealth visits. I agree to use a secure internet connection rather than public/free Wi-Fi, when possible.
Etiquette: The Health Center will not conduct a visit if I am engaged in an activity that could be dangerous if I were to become distracted (eg, driving a car; climbing a ladder). I will try my best to find a location free from loud background noise and distraction. Even relatively small things can cause distraction that interferes with the quality of the session – you will get more value from a visit when all your attention is focused on it. All participants must be appropriately dressed for every visit. I agree to be on time for my appointments, as this also helps keep my provider on time. MS Teams is to be used for scheduled appointments only; we expect appropriate use of the application and expect patients not to use MS Teams to initiate contact with providers between appointments.
Privacy: It’s my responsibility to maintain privacy on my end of the communication. I will use precautions to ensure that my communications are directed only to my provider, which includes ensuring that I am alone and in a private space during the visit. I will let my provider know if there is anyone else present. My provider will make me aware of any other personnel present on their end of the communication. Confidentiality still applies for telehealth services, and recording of sessions is not permitted by either party. We make every effort to ensure privacy by using a secure server, though as with any technological platform there is risk that electronic communications can become compromised.
Service: I understand that telehealth services may not be as complete as face-to-face services. There may be situations which require me to follow up in person at the clinic such as to obtain vital signs, complete labs, obtain an EKG, or be examined by a medical provider. Certain prescriptions may be obtained only at the Health Center at Auraria and could require I come in person to pick them up.
I am aware that my practitioner may contact the proper authorities and/or my designated, local contact person in case of an emergency. I acknowledge, however, that if I think I may be facing an emergency situation that could result in harm to me or to another person, I am not to seek a telehealth consultation as a first point of contact. Instead, I agree to seek care immediately through the nearest hospital emergency department or by calling 911.
I understand that I will be responsible for any fees, copayments, or coinsurances that apply to my telehealth visit. If any fee is incurred, a bill will be sent separately by mail. In the event of disruption of service, or for routine or administrative reasons, it may be necessary to communicate by other means, such as phone or email.
Cancellations: In the event that I need to cancel or reschedule an appointment, I understand that it is necessary to contact the front desk staff through the main clinic number at 303-615-9999 at least 24 hours in advance. Canceling the appointment in Microsoft Teams does not cancel the appointment in the Health Center at Auraria’s scheduling system; thus, not contacting the clinic to cancel may result in a missed appointment fee.