Consent for Telehealth at NorthStar Regional Mental Health Services

“Telehealth” is the provision of services using telecommunication and electronic technologies where the two individuals are physically located in two different locations from each other. You and the clinician will conduct the appointment via webcam and live, interactive audio.

Telehealth at NorthStar Regional was developed to reduce the barriers to accessing mental health services. Telehealth can be beneficial to clients who are unable to come to a physical office on a regular basis or to those where receiving access to specialty care is limited.

Telehealth offered by NorthStar Regional (NSR) is voluntary, and it may be ended by you at any time. Confidentiality is extremely important to us. Information that you reveal during treatment will be kept strictly confidential. The laws that protect the confidentiality of your personal information, such as HIPAA, also apply to telehealth at NSR. The platform used by NorthStar Regional to deliver HIPAA-compliant telehealth service delivery is Doxy.me. As such, information disclosed during the course of the session is generally confidential. There are exceptions to this, however, that include the following:

• If you disclose your intention to inflict physical harm to yourself or another person;
• If you disclose that physical or sexual abuse or serious neglect of a minor child has occurred;
• If we receive a signed, valid court order requesting records; and

There are risks and consequences of Telehealth, including, but not limited to, the possibility, despite reasonable efforts on the part of NorthStar Regional that: the transmission of your information could be disrupted or distorted by technical failures; the transmission of your information could be interrupted by unauthorized persons; and/or the electronic storage of your medical information could be accessed by unauthorized persons. The Doxy.me platform has a very high level of security to protect your health information. However, breaches (ie: hackers) are always a possibility with health information technology in the medical industry.

At times, Telehealth may not be as effective as face-to-face services. If a NSR provider believes you would be better served by another service delivery modality (e.g. face-to-face services), they will refer you to a professional who can provide such services in your area or recommend in-person office visits.

I have been issued, and read, the document “Telehealth Consent and Intake Tool” that describes telehealth at NorthStar Regional in much more detail. I have answered the questionnaire as completely as possible.