This form describes S.E.M.P.É.’s Telehealth treatment and payment policies and includes:
- Your consent to receive medical treatment from S.E.M.P.É.’s (and your other rights and responsibilities);
- Your agreement to receive services using telehealth technology; and
- Your agreement to pay in full any charges that are your responsibility.
1. I agree to receive telehealth services. Telehealth involves the delivery of health care services, including assessment, treatment, diagnosis, and education, using interactive audio, video, and data communications. During my visit, my S.E.M.P.É. provider and I will be able to see and speak with each other from remote locations.
2. I understand and agree that:
- I will not be in the same location or room as my mental health counselor.
- My S.E.M.P.É. provider is licensed in the state in which I am receiving services. I will report my location accurately during registration.
- I further understand that my S.E.M.P.É. Provider’s advice, recommendations, and or decisions may be based on factors not within his/her control, including incomplete or inaccurate data provided by me. I understand that my S.E.M.P.É. provider relies on information provided by me before and during our telehealth encounter and that I must provide information about my medical history, condition(s), and current or previous medical care that is complete and accurate to the best of my ability.
- I may discuss these risks and benefits with my S.E.M.P.É. provider and will be given an opportunity to ask questions about telehealth services. I have the right to withdraw this consent to telehealth services or end the telehealth session at any time without affecting my right to present or future treatment by S.E.M.P.É.
- I understand that the level of care provided by my S.E.M.P.É. provider is to be the same level of care that is available to me through an in-person medical visit. However, if my provider believes I would be better served by face-to-face services or another form of care, I will be referred to the nearest medical center, hospital emergency department or other appropriate health care provider.
- I have the right to receive face-to-face medical services at any time by traveling to a medical center that is convenient to me.
- In case of an emergency, I will dial 911 or go directly to the nearest hospital emergency room.
3. I consent to, understand and agree that:
- I have the right to discuss the risks and benefits of all procedures and courses of treatment proposed by my health care provider(s), together with any available alternatives.
- S.E.M.P.É. will provide care consistent with the prevailing standards of medical practice but makes no assurances or guarantees as to the results of treatment.
- I have the right to review and receive copies of my medical records, including all information obtained during a telehealth interaction, subject to S.E.M.P.É.’s standard policies regarding request and receipt of medical records and applicable law.
- The laws of the state in which I am located will apply to my receipt of telehealth services.