Consent to Treatment
This “Consent to Treatment” document provides you with additional information so that you can make an informed decision about whether to pursue treatment in our tele Neurology Clinics’ practice. It also reviews some procedures and expectations.
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WELCOME
Thank you for entrusting us with your health and wellbeing. We look forward to playing our role in helping you to be healthy and well. Please take a moment to read the following about our practice. Please click here to contact us via our secure, online form if you don’t understand anything here or have questions about it before consenting. We want you to feel empowered and that starts with being informed.
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OUR PRACTICE
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Participation in our telemedicine practice can result in a number of benefits to you as a patient, including improving your health and wellbeing. Working toward these benefits requires effort your our part as well as ours. Success requires honesty and openness in order to provide us with the best information so we can, in turn, give you the best care.
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COGNITIVE and BEHAVIORAL TREATMENT.
Depending on your clinical needs, you might be asked by our provider to remember or talk about unpleasant events, feelings, or thoughts. For some, this can be therapeutic. Feeling heard, understood and respected in those moments of raw vulnerability. For others, these discussions can result in you experiencing considerable discomfort or strong feelings of anger, sadness, worry, fear, etc., or experiencing anxiety, depression, insomnia, etc.. We will honor and respect your experience and treat you with care. You deserve that. As part of the therapeutic process, our provider might challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations, which can lead to novel insights sometimes, other times it might cause you to feel upset, angry, depressed, challenged, or disappointed. We will work with you to build trust. Our goal is your wellbeing and health.
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MEDICATIONS and TESTING
Our services might also include recommendations for you to consider prescription medication or over-the-counter medication, prescription or consumer devices, laboratory recommendations (including blood work and measures of physiology), imaging recommendations such as MRI or CT scans, cognitive behavioral therapy, couples counseling, spiritual guidance, personal coaching, relationship coaching, and others. We strive for the very best outcome for your health and wellbeing. But there is no guarantee that any of our recommendations will make you healthier or better. In fact, they sometimes can cause side effects, which are unwanted medical or psychological problems.
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Some medical tests that we recommend for you can reveal unanticipated problems. These are referred to as “incidental findings.” This might result in the need for further testing, need for other treatments or specialists, and uncertainty that can cause emotional stress.
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CONFIDENTIALITY
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All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your written permission except where disclosure is required by law. This includes situations where your provider believes that there is a risk of you harming yourself or someone else, or that abuse of a child or vulnerable adult is taking place in the present or has taken place in the past (whether or not you are directly involved). Disclosure might also be required pursuant to a legal proceeding by or against you, or to collect payment via a collections agency in cases of nonpayment.
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If you choose to include another party in your telemedicine care, it will only occur at your request and with your consent. Records for any sessions where multiple people are present (e.g., couple’s therapy) will require consent of all parties in order to be released. While the tele Neurology Clinics will not violate confidentiality outside the terms of this agreement, it is possible that the other parties to your session might disclose information outside of our control.
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LITIGATION LIMITATION
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Due to the nature of the medical process and the fact that it often involves making a full disclosure with regard to many matters which might be of a confidential nature, it is agreed that, should there be legal proceedings (such as, but not limited to divorce and custody disputes,, lawsuits concerning injury or harm, etc.), neither you nor your attorney, nor anyone else acting on your behalf will call on members of tele Neurology Clinics to testify in court or at any other proceeding, nor will a disclosure of the medical records be requested unless otherwise agreed upon. In the event that tele Neurology Clinics staff is subpoenaed to testify in court, a charge of $800 per hour will apply, and you will be responsible to pay for these additional fees. This hourly rate will include time during any deposition or court hearing, preparation for such testimony (e.g., gathering and/or reviewing documents for your record), travel time of our provider, emails and any other activity that requires our time.
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PAYMENTS & INSURANCE REIMBURSEMENT
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Tele Neurology Clinics does not accept medical insurance for payment of services. You will be responsible for, and need to pay for, services in full. Patients are expected to pay the agreed upon fees by the end of calendar date in which the session occurred, unless other arrangements have been made and mutually agreed in writing (including email). There might also be fees associated with requests by you (or anyone representing you) for documentation, telephone calls, texts and other patient-related matters, which will all be fee-billed at the $720 per hour rate. Invoice will be provided upon request.
A HIPAA-compliant, online portal for credit card payment is available on our website. Receipt will be provided to you if you enter your email in the payment portal. (This is not required.) At your discretion and your effort, you might choose to submit this receipt for partial reimbursement from your insurance company to you for treatment of our “out of network” services. There is no guarantee that you will be successful in obtaining reimbursement from your medical insurance.
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You are responsible for payment in full for all expenses, whether or not your insurance carrier will reimburse you for expenses. If your account is overdue and there is no written agreement on a payment plan, tele Neurology Clinics may use legal or other means (courts, collection agencies, etc.) to collect payment, and we reserve the right to temporarily or permanently discontinue your care by us.
MISSED APPOINTMENTS
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Session appointments that are cancelled less than 24 hours in advance of the scheduled time, or are missed for any reason, must be paid in full by the patient. Tele Neurology Clinics reserves the right to no longer see you as a patient until the bill has been payed in full. (Tele Neurology Clinics reserves the right to discontinue treatment of any patient for cause or without cause, and you have the right to discontinue treatment for cause or without cause as well.) If you have prepaid for a session and miss or cancel it less than 24 hours in advance you will not be refunded the money. If you wish to make up a missed session you will not be issued a refund and you will be required to pay for the rescheduled session at the regular rate.
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Patients arriving late for their appointment should still expect the session to end on scheduled time. If you do not show up for your session within 15 minutes of the scheduled start time and are not in contact with your provider, your provider will consider this a missed session for which you are fully responsible for payment of that entire session.
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ELECTRONIC COMMUNICATIONS
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All e-mails sent from the tele Neurology Clinics are securely encrypted and cannot be intercepted in transit by third parties. However, you are responsible for the security of your own e-mail accounts and devices. Additionally, e-mails you send to the tele Neurology Clinics are not guaranteed to be encrypted (although some e-mail providers do routinely automatically encrypt their e-mails as well).
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You may also request to communicate with the tele Neurology Clinics via unencrypted methods such as text messages or phone calls. If you choose to use unencrypted communication options, please be aware that any computer, unencrypted e-mail or text communication can be accessed by unauthorized people and hence can compromise the privacy and confidentiality of such communication.
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Unencrypted e-mails and texts are vulnerable to such unauthorized access due to the fact that servers or communication companies may have unlimited and direct access to all e-mails and texts that go through them. The following are some of the risks inherent in using these media:
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An unencrypted e-mail or text message might be sent erroneously to the wrong recipient, seen by someone in your house or workplace, or purposefully intercepted by a third party.
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Communication companies (e.g., Google) may be able to access e-mail accounts and text messages.
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Computers, tablets, and cell phones can be lost or stolen.
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These risks exist both for unencrypted messages sent by you or someone representing you, such as a loved one or personal assistant. (E-mails you receive from tele Neurology Clinics are always end-to-end encrypted.) In order to further address these possibilities from the side of tele Neurology Clinics, all e-mails bear a disclaimer in case of we mistakenly send an email to the wrong person, recipients. All confidential data is stored in HIPAA-compliant systems and on computers, tablets, and cell phones that are password-protected. Emails and text messages exchanged between you and your provider become a part of your record and subject to all the same laws and rights of access as any other part of your record.
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You are not required to use any unencrypted method of communication to receive treatment. For your convenience, you do have the right to request unencrypted communications. (You may revoke your request at any time.) If you initiate communication with your provider via unencrypted methods, we will assume that you have made an informed decision to use such communication methods. We will view this action by you as your agreement to accept the risks associated with such methods, and will honor your desire to communicate using these methods. You may also choose to communicate electronically only via secure means, by contacting us through the contact form on our website.
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CONTACT
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If you need to contact your provider between sessions, please email our office at admin@tele-neurology.com and we will alert your provider of the change.
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EMERGENCY PROCEDURES
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Tele Neurology Clinics is not an emergency or urgent-care clinic. If you having a medical problem requiring urgent or emergency care, it is best to call 9-1-1 and go to the nearest emergency room by ambulance.
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TELEMEDICINE
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As you consider whether telemedicine is the right choice for your medical care, please read our FAQ section (click here). It describes advantages and disadvantages of telemedicine. Our provider will help you assess if working via telemedicine is appropriate for your situation, and will provide guidance.
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Telemedicine can be impacted by technical failures. Most of these are minor and easily resolved (like forgetting to turn on your computer microphone). Others can be more serious, like unable to reach one another by power loss before or during a session or the ability of your medical provider to intervene if you are having an medical problem that requires in-person intervention, including a medical emergency.
OUR COMMUNICATION PLAN
In preparation for your visit, you will receive a link from us. It will bring you to a secure virtual meeting room shortly before your session. Your provider employs software and hardware tools that adhere to security best practices and applicable legal standards for the purposes of protecting your privacy and ensuring that records of your health care services are not lost or damaged.
If a video connection cannot be established due to technical problems, you have the option of proceeding with a phone session or cancelling the session at no charge. If a video call is dropped or disrupted, we will spend up to 5 minutes trying to reconnect before calling you on the phone number you have provided us with. If this happens during the first 10 minutes of a session, you have the option of proceeding with a phone session or cancelling the session at no charge. After the first 10 minutes, you will be charged for a full session whether or not you choose to continue by phone.
CREATING A PRIVATE CONVERSATION
You will be responsible for creating a safe and confidential space during sessions. It should be difficult or impossible for other people to see or hear your interactions with your provider during the session. This is easiest to achieve by you wearing headphones and being in a private room. But a private room is typically sufficient unless you think a person from outside the room can hear us speaking.
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As a recipient of our telemedicine services, you will need to participate in ensuring your safety. Your provider will require you to designate an emergency contact. You will need to provide permission for your provider to communicate with this person about your care during emergencies.
Please use reasonable security protocols to protect the privacy of your own health care information. For example: when communicating with your provider, we recommend you use devices and service accounts that are protected by unique passwords that only you know.
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PROHIBITION AGAINST RECORDING SESSIONS
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Your provider will never record video or audio sessions. You similarly agree to never record video or audio sessions. Making recordings can quickly and easily compromise your privacy and should be done with great care. ​
WELCOME
Once again, we thank you for entrusting us with your health and wellbeing. And we look forward to helping you to be your best self.
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