This document is serves as Valley Health Systems (VHS) informed consent for telehealth services.

Telehealth is offered to improve access to services at Valley Health. Telehealth is the delivery of healthcare services when the healthcare provider and patient are not in the same physical location through the use of technology. Electronically transmitted information may be used for screening, diagnosis, therapy, follow-up, and/or patient education and may include both patient medical records, as well as medical images. The results of telehealth cannot be guaranteed or assured.

All aspects of Valley Health’s informed consent for treatment apply to these services.

Please note:

• You are not required to use telehealth and have the right to request other service options or referrals or withdraw this consent at any time without affecting your right to future care or treatment at Valley Health.
• Telehealth may not be appropriate, or the best choice of services for a variety of reasons
• You have the right to request documentation regarding all transmitted medical information

All systems will incorporate network and software security protocol to protect the confidentiality of patient identification, including measures to safeguard the data and ensure its integrity against intentional or unintentional corruption. Telehealth services are conducted and documented in a confidential manner according to applicable laws in similar ways as in-person services.  There are, however, additional risks including:

• Sessions could be disrupted, delayed, or communications distorted due to technical failures.
• Telehealth involves alternative forms of communication that may reduce visual and auditory cues and increase the likelihood of misunderstanding one another.
• Your provider may determine that telehealth is not an appropriate treatment option
• In rare cases security protocols could fail and your confidential information could be accessed by unauthorized persons.

Valley Health Systems works to reduce these risks by only using secure videoconferencing software.  Should there be technical problems with video conferencing, the most reliable backup plan is contact by phone.

If your health care costs may be paid or partly paid by Medicare, Medicaid, or a health insurance plan, Valley Health will disclose to the payer such treatment information as it is necessary for payment. If you are under the age of 18, your parents or guardians may receive health care information about you from Medicaid or the insurance company or the plan under which you are covered. The circumstances under which we are required or authorized to share your health information with persons outside the VH workforce are outlined in the NOPP.  I understand that it is my responsibility to provide Valley Health Systems with my insurance/medical card information and that this information will be used in order to bill for Telehealth services rendered. The Telehealth visit is the patient responsibility, and payment in full is expected upon receiving billing statements.

AUTHORIZATION TO PAY BENEFITS TO PHYSICIAN: I authorize payment directly to Valley Health.
AUTHORIZATION TO RELEASE MEDICAL INFORMATION: I authorize Valley Health to release any information acquired in the course of Telehealth services in order to facilitate care or payment.

The person giving consent (patient or parent/guardian) has capacity to consent for medical treatment.

I have read and understand the above information and all my questions have been answered.  I hereby give informed consent to use telehealth in my care. This form is valid for one year from date of signature and must be updated annually or if any information changes.

Complete Informed Consent Form for Telehealth Services

This document is to serve as an addendum to the Valley Health Systems (VHS) behavioral health informed consent form and does not replace it.  All aspects of informed consent for treatment in that document apply to telemental health (TMH) treatment.  TMH refers to psychotherapy/counseling sessions that occur via phone or video conferencing using a variety of technologies.  TMH is offered to improve access to psychotherapy/counseling services to Valley Health patients when significant barriers of travel to another clinic exist.  However, the results of TMH cannot be guaranteed or assured.  You are not required to use TMH and have the right to request other service options or referrals or withdraw this consent at any time without affecting your right to future care or treatment at Valley Health.  TMH services may not be appropriate, or the best choice of service for reasons including, but not limited to: heightened risk of harm to oneself or others, active psychosis, active intoxication on drugs or alcohol, difficulty with communications technology, significant communication service disruptions, or need for more intensive mental health services.  In these cases, your therapy provider will help you establish referrals to other appropriate services.

TMH services are conducted and documented in a confidential manner according to applicable laws in similar ways as in-person services.  There are, however, additional risks including:

• Sessions could be disrupted, delayed, or communications distorted due to technical failures.
• TMH involves alternative forms of communication that may reduce visual and auditory cues and increase the likelihood of misunderstanding one another.
• Your therapy provider may determine that TMH is not an appropriate treatment option or stop TMH treatment at any time if your condition worsens, does not improve over time or if TMH presents barriers to good care.
• In rare cases security protocols could fail and your confidential information could be accessed by unauthorized persons.

Valley Health Systems works to reduce these risks by only using secure videoconferencing software.  Should there be technical problems with video conferencing, the most reliable backup plan is contact by phone.  You will be able to utilize an office phone at the Valley Health clinic from which you receive TMH services.  If there are also outages with the phone lines, you may have to be rescheduled either later that day, if schedules permit, or for a different day.

As there are inherent risks to mental illness and its treatment, the following are recommended in times of medical emergency or extreme emotional distress.

• Contact 911 and/or proceed to the nearest emergency room. I, my partner, Medical Power of Attorney, next of kin, or closest associate will inform the emergency personnel of any medications that I am taking, of all outpatient treatments that I am engaged in, as well as any history of unsafe behaviors, as this information is critical in managing psychiatric emergencies.
• If I believe I am experiencing extreme psychological distress and am contemplating suicide or homicide, I will call 911, and/or present to the nearest emergency room, or inpatient facility such as River Park Hospital in Huntington, Charleston Area Medical Center in Charleston, or Highland Hospital in Charleston. I understand that the Valley Health System office locations are not equipped to handle psychiatric safety emergencies, as these require a higher level of care. I have also been provided with crisis phone numbers by my therapy provider to call in times of crisis.
• If I need to speak to a Valley Health provider after hours I may call the office and be transferred to an answering service. The answering service will contact the provider on call. This provider will have access to my health records and will work to resolve my need. The provider on call may recommend that I seek additional services by following up with my physician or in emergency situations, recommend I seek emergency medical care.  I understand that this provider will NOT be a behavioral health specialist, and while addressing any urgent emergencies, they may defer any treatment decisions to my regular mental health provider on the next business day.

If your health care costs may be paid or partly paid by Medicare, Medicaid, or a health insurance plan, Valley Health will disclose to the payer such treatment information as it is necessary for payment. If you are under the age of 18, your parents or guardians may receive health care information about you from Medicaid or the insurance company or the plan under which you are covered. The circumstances under which we are required or authorized to share your health information with persons outside the VH workforce are outlined in the NOPP.  I understand that it is my responsibility to provide Valley Health Systems with my insurance/medical card information and that this information will be used in order to bill for Telehealth services rendered. The Telehealth visit is the patient responsibility, and payment in full is expected upon receiving billing statements.

AUTHORIZATION TO PAY BENEFITS TO PHYSICIAN: I authorize payment directly to Valley Health.
AUTHORIZATION TO RELEASE MEDICAL INFORMATION: I authorize Valley Health to release any information acquired in the course of Telehealth services in order to facilitate care or payment.

The person giving consent (patient or parent/guardian) has capacity to consent for medical treatment.

I have read and understand the above information and all my questions have been answered.  I hereby give informed consent to use Telemental Health in my care. This form is valid for one year from date of signature and must be updated annually or if any information changes.

Complete Informed Consent Form for Telemental Health Services

This document serves as the Valley Health Systems (VHS) informed consent for teledental services.

Teledentistry is offered to improve access to services at Valley Health. Teledentistry is the delivery of dental services when the healthcare provider and patient are not in the same physical location through the use of technology. Electronically transmitted information may be used for emergency and/or patient education and may include both patient dental records, as well as dental images (not including X-rays). The results of teledentistry cannot be guaranteed or assured.

All aspects of Valley Health’s informed consent for treatment apply to these services.

Please note:

• You are not required to use teledentistry and have the right to request other service options or referrals or withdraw this consent at any time without affecting your right to future care or treatment at Valley Health.
• Teledentistry may not be appropriate, or the best choice of services for a variety of reasons
• You have the right to request documentation regarding all transmitted dental information

All systems will incorporate network and software security protocols to protect the confidentiality of patient identification, including measures to safeguard the data and ensure its integrity against intentional or unintentional corruption. Teledentistry services are conducted and documented in a confidential manner according to applicable laws in similar ways as in-person services.  There are, however, additional risks including:

• Sessions could be disrupted, delayed, or communications distorted due to technical failures.
• Teledentistry involves alternative forms of communication that may reduce visual and auditory cues and increase the likelihood of misunderstanding one another.
• Your provider may determine that teledentistry is not an appropriate treatment option
• In rare cases security protocols could fail and your confidential information could be accessed by unauthorized persons.

Valley Health Systems works to reduce these risks by only using secure videoconferencing software.  Should there be technical problems with video conferencing, the most reliable backup plan is contact by phone.

If your health care costs may be paid or partly paid by Medicaid, or a health insurance plan, Valley Health will disclose to the payer such treatment information as it is necessary for payment. If you are under the age of 18, your parents or guardians may receive health care information about you from Medicaid or the insurance company or the plan under which you are covered. The circumstances under which we are required or authorized to share your health information with persons outside the VH workforce are outlined in the NOPP.  I understand that it is my responsibility to provide Valley Health Systems with my insurance/medical card information and that this information will be used in order to bill for Teledentistry services rendered. The Telehealth visit is the patient responsibility, and payment in full is expected upon receiving billing statements. This includes sliding fee patients.

AUTHORIZATION TO PAY BENEFITS TO DENTIST: I authorize payment directly to Valley Health.

AUTHORIZATION TO RELEASE DENTAL INFORMATION: I authorize Valley Health to release any information acquired in the course of Teledentistry services in order to facilitate care or payment.

The person giving consent (patient or parent/guardian) has capacity to consent for medical treatment.

I have read and understand the above information and all my questions have been answered.  I hereby give informed consent to use teledentistry in my care. This form is valid for one year from date of signature and must be updated annually or if any information changes.

Complete Informed Consent for Teledentistry Services