The purpose of this notice is to obtain your consent for a telehealth consultation if you are referred to or receive a consultation from a Ginger therapist or psychiatrist.
NATURE OF TELEHEALTH CONSULTATION
Telehealth involves the use of audio, video, or other electronic communication to enable your health care provider to interact with you and provide medical consultation, therapy, or treatment from a remote location. Video-conferencing technology will be used by your provider to facilitate the telehealth session. With your consent, the session may be recorded for quality review, operations, training, research, and safety purposes.
I understand that a video consultation will not be the same as an in-person visit with a healthcare provider due to the fact that I will not be in the same room as my therapist or psychiatrist.
RISKS, BENEFITS AND ALTERNATIVES
The benefit of telehealth includes the ability for you to access your healthcare provider from your home or other location using the Internet. Potential risks of the Ginger telehealth platform include:
- technical problems such as unclear video, loss of sound, or connection interruption that may require a session to be rescheduled or require a followup face-to-face consultation
- in rare circumstances, security measures could fail causing a potential breach of personal medical information
I understand that I, or my Ginger therapist or psychiatrist, may discontinue or reschedule a telehealth consultation if the video quality or audio connection is not adequate for the situation.
CONFIDENTIALITY
Personal information that Ginger uses or maintains, including your telehealth sessions, is confidential and subject to laws that protect health information, including the Health Insurance Portability and Accountability Act (HIPAA) pursuant to Ginger’s Privacy Statement and Notice of Privacy Practices.
I understand that my healthcare information may be shared confidentiality with my care team and other authorized individuals when required for my treatment, healthcare operations, and billing purposes.
BILLING AND PAYMENT
Ginger will bill your health plan and/or insurance company for services provided.
I understand that I am responsible for payment of any deductible, coinsurance, or co-pay amounts as stipulated by my insurance plan.
EMERGENCIES
In an emergency situation, to ensure my safety or the safety of others, I understand that the responsibility of the telehealth provider may include contacting my local practitioner, emergency services, or law enforcement, including 911 services.
QUESTIONS
You have the opportunity to ask your provider questions about telehealth prior to receiving the services to better understand the risks, benefits and any practical alternatives described in this consent.
I CERTIFY THAT:
- I have read this form and fully understand its contents including the risks and benefits of the services
- I may ask my provider questions regarding the benefits and risks of telehealth and ensure those questions are answered to my satisfaction prior to receiving services.
- I hereby give consent to telehealth as an acceptable form of delivering healthcare services to me and that this consent will cover any and all of my sessions using telehealth.
