Informed Consent for Telehealth Services

Telehealth Services

I understand that telehealth allows my healthcare provider and me to communicate and receive healthcare services while we are in different physical locations.

Telehealth services provided by Luminox Healthcare Services LLC may include psychiatric evaluations, medication-management appointments, follow-up visits, psychotherapy or supportive interventions when applicable, patient education, treatment planning, and other clinically appropriate behavioral and mental healthcare services.

Video telehealth appointments are generally conducted through Tebra. I may receive a secure link or other instructions that allow me to join my scheduled appointment.

When clinically appropriate or requested, certain encounters or communications may be conducted by telephone or audio-only technology, including through RingCentral.

I understand that my provider will determine whether telehealth or audio-only care is clinically appropriate based on my individual circumstances and applicable legal and professional requirements.

Benefits and Limitations of Telehealth

I understand that potential benefits of telehealth may include improved access to healthcare, convenience, reduced travel, and the ability to receive care from an appropriate private location.

I understand that telehealth also has limitations and potential risks. These may include:

• Internet, telephone, equipment, or software failure;
• Interrupted or delayed communication;
• Poor audio or video quality;
• Unauthorized access or other privacy or cybersecurity risks;
• Limitations in the provider's ability to conduct certain physical examinations or assessments remotely; and
• Circumstances in which telehealth may not be clinically appropriate for my condition.

If my provider determines that an adequate or safe evaluation or treatment cannot be provided remotely, I understand that my provider may recommend an in-person evaluation, another healthcare provider, a higher level of care, emergency evaluation, or another clinically appropriate service.

Patient Identity, Physical Location, and Participants

I understand that I may be asked to confirm my identity and current physical location at the beginning of a telehealth encounter.

I understand that the state or jurisdiction in which I am physically located at the time of my appointment may affect whether my provider is legally permitted to provide healthcare services to me.

I may also be asked to provide or confirm a telephone number where I can be reached and current emergency-contact information.

I agree to inform my provider if another individual is present or is able to hear or observe my telehealth encounter. Luminox Healthcare Services LLC will similarly identify other authorized individuals participating in my care when appropriate.

Privacy and Confidentiality

Luminox Healthcare Services LLC will use reasonable administrative, technical, and physical safeguards to protect my health information in accordance with applicable federal and state privacy and security laws.

I understand that electronic communications and telehealth technologies may carry privacy and cybersecurity risks and that no electronic communication system can be guaranteed to be completely free from such risks.

I am encouraged to participate in telehealth appointments from a reasonably private location, use a secure internet connection when possible, protect my passwords and electronic devices, and avoid sharing my appointment link or portal credentials with unauthorized individuals.

I understand that information discussed during my treatment is generally confidential but that confidentiality is subject to exceptions permitted or required by law. These may include certain circumstances involving imminent safety concerns, suspected abuse or neglect, court orders or other legal processes, public-health requirements, or other disclosures permitted or required by applicable law.

Recording, Transcription, and Technology-Assisted Clinical Documentation

I understand that certain telehealth or telephone encounters may be recorded, transcribed, summarized, or processed using authorized technology to assist with clinical documentation, quality assurance, patient safety, and other lawful healthcare operations.

Luminox Healthcare Services LLC may use MDHUB or other authorized clinical documentation technology to assist with recording, transcription, summarization, and preparation of clinical documentation.

Tebra may be used for video telehealth encounters, and RingCentral may be used for telephone or audio-only communications.

When an encounter will be recorded or transcribed, I will be informed as required by applicable law, and my consent will be obtained when required.

Recordings, transcripts, summaries, and other information generated from an encounter will be treated as protected health information when applicable and will be accessed, maintained, retained, or disposed of in accordance with applicable privacy and security requirements and Luminox Healthcare Services LLC policies.

I understand that technology-assisted transcription and documentation may contain errors, omissions, or inaccuracies. My healthcare provider remains responsible for reviewing and appropriately documenting the clinical encounter.

I understand that I may ask questions about the use of recording, transcription, or technology-assisted documentation. My ability to decline recording or transcription, and whether an alternative method of providing or documenting the service is available, will be addressed in accordance with applicable law, clinical requirements, and practice policy.

Emergency and Crisis Situations

I understand that telehealth services provided by Luminox Healthcare Services LLC are not a substitute for emergency medical or psychiatric services.

If I am experiencing an immediate or life-threatening medical or psychiatric emergency, I should call 911 or go to the nearest emergency department. When appropriate, I may also contact 988, the Suicide & Crisis Lifeline, for crisis support.

If my provider reasonably believes that I or another person may be in imminent danger or that an emergency exists, I understand that my provider may take clinically and legally appropriate actions to facilitate emergency assistance. This may include contacting emergency medical services, law enforcement when appropriate, my emergency contact, or other appropriate resources as permitted or required by law.

I understand that this is one reason my provider may confirm my current physical location and emergency contact information during telehealth care.

Technical Difficulties or Disconnection

If a video or telephone connection is interrupted, lost, or becomes inadequate for the clinical situation, my provider and I may attempt to reconnect, transition to another clinically appropriate communication method, reschedule the appointment, or determine whether another method or level of care is necessary.

I understand that technical difficulties may interrupt, delay, or limit an encounter.

Clinical Decision-Making and Treatment

I understand that receiving services through telehealth does not guarantee a particular diagnosis, treatment, medication, prescription, or clinical outcome.

My healthcare provider will exercise independent professional judgment in determining whether a particular evaluation, treatment, medication, or other intervention is clinically appropriate.

I understand that I may ask questions regarding my care and discuss reasonable treatment alternatives with my provider.

When clinically appropriate and reasonably available, alternatives to telehealth may include in-person evaluation or referral to another appropriate healthcare service.

Voluntary Participation and Withdrawal of Consent

I understand that participation in telehealth is voluntary.

I have the right to ask questions regarding telehealth before or during treatment.

I may withdraw my consent to telehealth services, subject to applicable law and clinical circumstances. Withdrawal of consent will not affect the legality or validity of healthcare services already provided.

If I decline telehealth or telehealth is no longer clinically appropriate, Luminox Healthcare Services LLC may discuss reasonable alternatives or provide information regarding other appropriate healthcare resources.

Patient Responsibilities

I agree to provide accurate and complete information that is reasonably necessary for my healthcare.

I agree to inform my provider of significant changes in my health, medications, symptoms, location, or other information relevant to my treatment.

I will not knowingly share my telehealth appointment link, patient portal credentials, passwords, or other secure access information with unauthorized persons.

I understand that I am responsible for taking reasonable precautions to protect the privacy and security of my own device, telephone, internet connection, email account, passwords, and physical surroundings.

I understand that participation in a telehealth appointment while driving or operating a vehicle or other hazardous equipment may be unsafe. I agree to participate from a safe location appropriate for the clinical encounter.

Insurance Coverage and Financial Responsibility

If I intend to use health insurance, I understand that coverage for telehealth or other healthcare services depends upon my individual insurance plan, eligibility, benefits, network requirements, and applicable payer policies.

I understand that verification of insurance eligibility or benefits is not a guarantee of payment by my insurance company.

I understand that I may be financially responsible for applicable copayments, coinsurance, deductibles, self-pay charges, non-covered services, or other patient responsibility in accordance with Luminox Healthcare Services LLC's financial policies, my insurance benefits, and applicable law.

Applicable patient payments may be collected at the time of service in accordance with practice policy.

Safe and Respectful Treatment Environment

Luminox Healthcare Services LLC is committed to maintaining a safe and respectful environment for patients, providers, staff, and others.

Threats of violence, acts of violence, harassment, or other conduct presenting a significant safety risk may result in appropriate safety measures and may affect continuation of the treatment relationship.

When termination of an established treatment relationship is clinically and legally appropriate, Luminox Healthcare Services LLC will address continuity of care in accordance with applicable professional standards and legal requirements.

Immediate safety measures may be taken when reasonably necessary to protect the patient, healthcare providers, staff, or others.

No Guarantee of Treatment Outcome

I understand that healthcare outcomes cannot be guaranteed.

Although my provider will use appropriate professional judgment in evaluating and treating me, Luminox Healthcare Services LLC does not guarantee that telehealth, medication management, psychotherapy, or any other treatment will result in a particular outcome.

Communication With the Practice

I understand that routine questions and communications may be submitted through communication methods authorized by Luminox Healthcare Services LLC.

I understand that electronic or portal messages are not appropriate for emergencies and may not be reviewed immediately.

If I am experiencing an emergency, I will call 911 or go to the nearest emergency department rather than relying on a portal message, email, voicemail, or other routine communication with the practice.

Right to Ask Questions

I understand that I may ask questions regarding telehealth, privacy, confidentiality, technology, recording or transcription, treatment procedures, potential benefits and risks, and reasonable alternatives.

I have had an opportunity to request clarification regarding any part of this consent that I do not understand.

Patient Acknowledgment and Consent

By electronically signing this form, I acknowledge and agree that:

• I have read this consent, have had it read to me, or have had its contents explained to me in a manner that I understand.
• I understand the nature, potential benefits, limitations, and reasonably foreseeable risks associated with telehealth.
• I understand that telehealth is not an emergency service.
• I understand that video telehealth services may be provided through Tebra and that certain telephone or audio-only communications may occur through RingCentral.
• I understand that MDHUB or other authorized clinical documentation technology may be used to assist with recording, transcription, summarization, and preparation of clinical documentation, subject to applicable privacy, security, notice, and consent requirements.
• I understand that I may be asked to confirm my identity, physical location, telephone number, and emergency contact information.
• I understand my rights regarding privacy and confidentiality and recognize that certain disclosures may be permitted or required by law.
• I understand that I may ask questions about my treatment and telehealth services.
• I understand that I may withdraw my consent to telehealth, subject to applicable law and clinical circumstances.
• I understand that signing this document does not waive any rights or protections available to me under applicable federal or state law.
• I voluntarily consent to receiving clinically appropriate telehealth and/or audio-only healthcare services from Luminox Healthcare Services LLC.