I hereby consent for my child/self to participate in telehealth services with Families and Community Together (FACT).
I understand the following will apply:
1. I understand that telehealth is the practice of delivering Care Management services via technology-assisted media or other electronic means between an FACT Staff member and a youth/family who are located in two (2) different locations. The benefits of telehealth may include removing transportation and travel barriers, and minimize face-to-face interactions to limit the exposure of COVID-19.
2. I understand that I have the right to withdraw this consent for myself/child to participate in telehealth at any time without affecting my child’s/my right to future care or treatment or risking the loss or withdrawal of any program benefits at FACT to which would otherwise be provided.
3. I understand that there are risks and consequences associated with telehealth. These include but are not limited to technology limitations and failures; interruptions and/or confidentiality issues because other persons may be present during the telehealth session; limited ability to see or hear things that are crucial to the session; and/or the limited ability for FACT to respond to an emergency that they are made aware of during a telehealth session. I also understand that telehealth may not be as effective as in-person health services.
4. I understand that recording, taking screenshots, etc., of any kind during any telehealth session is strictly prohibited.
5. I understand that all laws relating to confidentiality of records; all provisions of the FACT Notice of Privacy Practices that I received; and all provisions of the Informed Consent will apply to the telehealth process. All information disclosed during sessions and all information that FACT places in its records will be kept confidential in accordance with applicable law, except where I have authorized the disclosure pursuant to a separate authorization or as otherwise required by law.
6. I understand that to conduct the telehealth session, FACT will use a third party platform (Microsoft Teams) and that platform has represented that it is compliant with the Health Insurance Portability and Accountability Act of 1996 and its implementing regulations, as amended (“HIPAA”). FACT assumes no liability or responsibility for the failure of the platform to be HIPAA-compliant or to safeguard and/or protect my confidentiality. I will advise my Care Manager immediately if I wish to use a different third party platform to conduct the telehealth session and in extenuating circumstances FACT may grant such request. I understand and acknowledge that there may be risks associated with the use of any other third party platform and I agree to hold FACT harmless for all losses resulting from the use of any other third party platform. FACT reserves the right to deny requests to use any other third party platform. In the event that FACT denies my request to use any other third party platform, FACT will let me know why it is denying the request and offer other alternatives to conduct the session (i.e., telephone conference).
7. I understand that I and/or my child is/are expected to be available, focused and engaged in telehealth session(s).
8. I understand that in order to protect confidentiality, we cannot share the links to any telehealth sessions and that the session needs to occur in a private location where we can speak openly without being overheard or interrupted by others. If someone comes into the room during a session or if confidentiality is somehow affected, we agree to advise FACT immediately so that we can discuss the best way to handle. FACT assumes no responsibility for breaches of confidentiality that may occur due to the failure to participate in a telehealth session in a private location or to failure to safeguard any telehealth links.
9. I understand that if FACT believes that another form of communication would better serve my child or me, telehealth will no longer be used.
10. I agree to call 911 or to go to my local emergency room immediately if my child is in crisis during a telehealth session.
I understand that the time for any meeting is specifically reserved for me/my child and we are responsible for joining the meeting on time. If I/my child is late, the appointment will still end at the scheduled end time. If we need to cancel or reschedule a session, I will contact the Care Manager prior to the scheduled meeting time.
I understand that FACT assumes no responsibility for my/my child’s failure to participate in a session, in whole or in part, due to issues caused by us, including but not limited to dead or uncharged equipment batteries; malfunctioning equipment; poor reception due to location; or failure to obtain a confidential place to participate in the session.
I understand that during a telehealth session, technical difficulties beyond both FACT’s and our control could result in service interruptions. If this occurs, we will end and restart the session. If we are unable to reconnect within fifteen (15) minutes following any service interruption, the meeting organizer will reach out to us to discuss or to reschedule, if need be.
I understand that telehealth may or may not be authorized by the Department of Children and Families and the Center for Medicaid Services in the future. If these entities do not approve the use of telehealth for the provision of Care Management services, FACT may be unable to continue to utilize telehealth.
I will not hold FACT responsible for any technical failures during the telehealth encounter beyond the control of FACT, including any resulting delays in evaluation or for information lost due to such technical failures.
I understand that I need to inform FACT of my child’s location at the start of any session in case of an emergency and to provide the name of a contact person who FACT can communicate with on my/my child’s behalf in case of a life-threatening emergency that arises during a session.
I have read and understood the foregoing. The risks of telehealth have been explained to me and I have had the opportunity to ask questions. I hereby consent to participate in telehealth with FACT.