Tele-therapy Consent Form

Tele-therapy Consent

I understand that tele-therapy involves the use of electronic information and communication technologies by a health care provider to deliver services to an individual when he/she is located at a different site than the provider; and hereby consent to receiving health care services to me via tele-therapy over secure video conferencing platform and other communication and electronic tools. I understand that the laws that protect privacy and the confidentiality of my medical information also apply to tele-therapy. Please note that with the current healthcare crisis of COVID-19, fines for failure of HIPAA compliance are not being assessed. The platform selected by Leaps and Bounds Therapy, LLC is the free version of Zoom (or facetime if the family prefers over zoom), which are not HIPAA compliant. Leaps and Bounds Therapy, LLC will nonetheless work to protect by health information such as locking sessions, not recording our sessions, and limiting explicit discussions of protected health information on the platform. Should a HIPAA compliant version become available at a lower cost point, Leaps and Bounds Therapy, LLC will switch immediately to such a system. I understand that Leaps and Bounds Therapy, LLC’s payment policy is the same for tele-therapy appointments as in-person appointments. Leaps and Bounds Therapy, LLC does not guarantee any payment by insurance companies. The patient is responsible for the balance payment of all services rendered after insurance coverage has been processed and applied. I understand that there are potential risks involving technology, including but not limited to: Internet interruptions, and technical difficulties. I understand that technical difficulties with hardware, software, and internet connection may result in service interruption and that we are not responsible for any technical problems and do not guarantee that services will be available or work as expected. I understand that I am responsible for information security on my computer and in my own physical location. I understand that I am responsible for creating and maintaining my user name(s) and password(s) and not share these with another person. I understand that I am responsible to ensure privacy at my own location by being in a private location so other individuals cannot hear my conversation. I understand that either I or my Therapist can discontinue the tele-therapy services if it is felt that this type of service delivery does not benefit my/my child’s needs or for any other reason. Please print, sign and return the signature below to your provider before tele-therapy services can initiate I have read and understand the information provided above regarding tele-therapy, have discussed it with my therapist and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of tele-therapy. By signing I state that I have read, understand and agree to the Tele-therapy Consent above:
Child's Name
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Parent or Guardian Signature
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