OncoHealth Medical Group, P.A.
By choosing Get Started, I am agreeing to participate in telemental health services with licensed professionals at OncoHealth Medical Group, P.A (“OncoHealth Medical Group”). I understand that telemental health is the practice of delivering clinical mental health care services via technology assisted media or other electronic means between a practitioner and a participant who are in two different locations. This document is to inform you about and obtain your consent regarding your participation in telemental health services with OncoHealth Medical Group.
The benefits to telemental health services are:
The ability to expand your choice of service provider, particularly in this case to oncology mental health specialists who may be available in limited numbers in your geographic region.
More convenient therapy options including location, time, no driving, etc.
Reduces the overall cost and time of therapy due to not having to drive to and from an office.
Ability to have real time monitoring and reduces the wait time for scheduling office appointments.
Increased availability of services to homebound clients, clients with limited mobility, and clients without convenient transportation options.
It is important to note that there are limitations to telemental health services that can affect the quality of the session(s). These limitations include, but are not limited to, the following:
Technology might fail before or during the session.
Due to technology limitations, we may not hear all of what you are saying and may need to ask you to repeat things.
Although every effort is made to reduce confidentiality breaches, breaches may occur for various reasons.
OncoHealth Medical Group’s licensed professionals can only practice in the states(s) where they are licensed. That means that wherever you are located for the session, the licensed professional must be licensed in that state. You agree to inform the licensed professional if your physical location has changed or if you have relocated your domicile to a different jurisdiction.
I understand and agree to the following with respect to engaging in telemental health services with OncoHealth Medical Group:
I understand that I will be conducting sessions with OncoHealth Medical Group’s licensed professionals on a HIPAA compliant platform. I agree I will be available at the scheduled time and be prepared, focused and engaged in the session. I will be in a private location where I can speak openly without being overheard or interrupted by others to protect my confidentiality. If I choose to conduct my session in a place where there are people or with others who can hear me, OncoHealth Medical Group is not responsible for protecting my confidentiality and I am agreeing to the disclosure of my mental health information to those who are with or around me.
I understand that I have the right to withdraw consent at any time without affecting my right to future care, services, or program benefits to which I would otherwise be entitled.
I understand that there are risks, benefits, and consequences associated with telemental health, including but not limited to, disruption of transmission by technology failures, interruption and/or breaches of confidentiality by unauthorized persons, limits to knowledge about local resources, and/or limited ability to respond to emergencies.
I understand that there will be no recording of any of the online sessions by either party. All information disclosed within sessions and written records pertaining to those sessions are confidential and may not be disclosed to anyone without written authorization, except where the disclosure is permitted and/or required by law.
I understand that my therapist or psychiatrist may occasionally find it helpful to consult other professionals – either as individuals or in a consultation group about a case. The consultant(s) is/are also legally bound to keep the information confidential. Unless you object, your therapist or psychiatrist will not tell you about these consultations unless they feel that it is important to your treatment. Authorized OncoHealth Medical Group clinical professionals may review your records to ensure the quality and consistency of care, your safety, member safety, and to review provider performance. This informed consent document allows your provider to share information and records for the purposes described and with others to facilitate your care and treatment in compliance with state and federal laws (such as HIPAA) and our Notice of Privacy Practices.
I understand, I am providing informed consent for OncoHealth Medical group to use or disclose my protected health information to provide continuity of care, coaching, telehealth services, and therapy sessions. My information may be disclosed to OncoHealth Medical Group licensed health professionals including doctors, nurses, therapists, other healthcare providers and peer mentors who are involved in take care of my health.
I understand that OncoHealth Medical Group will never share psychotherapy notes unless I give written permission, or as required by law, health and safety, or a government agency.
I understand that the privacy laws that protect the confidentiality of my protected health information(PHI) also apply to telemental health unless an exception to confidentiality applies (i.e. mandatory reporting of child, elder, or vulnerable adult abuse; danger to self or others; I raise mental/emotional health as an issue in a legal proceeding).
I understand that if I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms, have cognitive difficulties that would impact care or experiencing a mental health crisis that cannot be resolved remotely, it may be determined that telemental health services are not appropriate and a higher level of care is required. If I am in crisis or encountering an emergency, I agree to immediately call 911. If a situation occurs where we are talking and get disconnected and I am in crisis, I will call 911 or go to my local emergency room immediately. If OncoHealth Medical Group has concerns about your safety at any time during a session, it may break confidentiality and call 911 or any emergency contact provided.
I understand that during a telemental health session, we could encounter technical difficulties resulting in service interruptions. If this occurs, end and restart the session. If we are unable to reconnect, the mental health provider will contact me at my provided phone number to make alternative arrangements.
I understand that telemental health through OncoHealth Medical Group is limited to mental health issues related to the experience of cancer and that I will need to seek mental health care not related to cancer elsewhere.
Historically, mental health services have been associated with absolute confidentiality between the participant and the clinician. Currently, Federal and state laws and regulations and professional ethics require clinicians to maintain complete confidentiality of information and communications revealed in the course of treatment.
I understand the OncoHealth Medical Group clinician cannot release any psychotherapy notes without my expressed and informed permission, which is set forth in this consent. Psychotherapy notes are notes recorded by my health care provider who is a mental health professional documenting or analyzing the contents of a conversation during a private counseling session or a group, joint or family counseling session and that are separate from the rest of my medical record.
There are some exceptional circumstances where OncoHealth Medical Group clinicians may be required or permitted to communicate information about mental health services. Circumstances include the following situations:
You present a clear and present danger to yourself and refuse to accept appropriate treatment.
You communicate to the clinician an imminent threat of physical violence against a clearly identified or reasonably identifiable victim, or the clinician has a reasonable basis to believe there is a clear and present danger of physical violence against such a victim.
You introduce your mental condition as a defense in a legal proceeding.
In child custody or adoption cases, the judge determines that the clinician has information bearing significantly on the client's ability to provide suitable care or custody and this information bears significantly on the welfare of the child.
You initiate legal action against the clinician, and client information is necessary or relevant to the clinician's defense.
The clinician has grounds to believe a child under the age of 18, an elderly person (over age 60), or a handicapped adult, has been or is at risk of being abused or neglected.
A Judge orders a clinician to release client information.
I understand that I may sign a Release of Information and that Treatment Summary letters may be provided in lieu of releasing my complete psychological records to a requesting party.
By choosing Get Started and participating in telemental health services shows that I have read, understand and agree with all of the statements within this Consent for Treatment. An electronic copy of this agreement will be considered valid and as an original. My agreement to this consent also shows that I have received OncoHealth Medical Group’s Notice of Privacy Practices regarding the use and disclosure of my Protected Health Information. I consent to the use and disclosure of my Protected Health Information as per the Notice of Privacy Practices for the purposes of Treatment, Payment and Health Care Operations. Information such as counseling session start and stop times, the modalities and frequencies of the treatment furnished, results of clinical tests, summaries of diagnosis, functional status, treatment plan, symptoms, prognosis and process to date are not considered psychotherapy notes and are subject to the Notice of Privacy Practices regarding the use and disclosure of Protected Health Information.