I consent to engaging in telehealth services with MK Care Incorporation as part of my therapy and treatment goals. I understand that telehealth psychotherapy may include mental health evaluation, assessment, consultation, treatment planning, and therapy services. Telehealth services will occur primarily through interactive audio/video platforms or, when appropriate, by telephone.

 

 

Many insurance companies cover telehealth services. I understand that it is my responsibility to verify my insurance benefits, and that any quote of benefits provided by an insurance company is not a guarantee of payment. I understand that I am financially responsible for any services not covered by insurance, including co-payments, coinsurance, or deductibles.

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If I fail to cancel a scheduled appointment without giving proper advance notice, my therapist is unable to use this time for another client or being reimbursed by the insurance company. Therefore, an $150.00 fee will be charged for missed appointments or cancellations with less than a 24-hour notice unless it is due to illness or an emergency.

 

Rights and Responsibilities Related to Telehealth

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I understand that I have the following rights and responsibilities with respect to telehealth services:

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1. Right to Withdraw Consent
I have the right to withhold or withdraw my consent to telehealth services at any time without affecting my right to future care or treatment, and without jeopardizing any program benefits to which I would otherwise be entitled.

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2. Confidentiality
The same laws and professional standards that protect the confidentiality of my personal health information also apply to telehealth services. Information disclosed during sessions is generally confidential. There are mandatory and permissive exceptions to confidentiality, including but not limited to: suspected child or vulnerable adult abuse, expressed imminent risk of harm to myself or others, or disclosure required by law or court order.

I understand that personally identifiable images or information from telehealth sessions will not be shared with third parties without my written consent.

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3. Risks and Limitations of Telehealth
I understand that telehealth services involve potential risks, including but not limited to the possibility that, despite reasonable efforts by MK Care Incorporation, electronic communications may be disrupted, distorted, or accessed by unauthorized individuals due to technical failures or security breaches.

MK Care Incorporation utilizes HIPAA-compliant platforms for telehealth services. I understand that I am responsible for having appropriate access to the necessary technology and internet services.

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I understand that while I may benefit from telehealth services, results cannot be guaranteed. I also understand that telehealth services may not be as comprehensive as in-person services. If my therapist determines that I would be better served by in-person care or other interventions, they will recommend appropriate services and, when possible, assist me with referrals.

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4. Limits of Confidentiality Technology
While reasonable efforts will be made to maintain confidentiality, I understand that 100% confidentiality cannot be guaranteed due to factors outside the control of MK Care Incorporation, including third-party service providers and their servers. By signing this form, I acknowledge these risks and agree not to hold MK Care Incorporation or its staff liable for the collection or use of client information by such service providers.

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5. Licensing and Jurisdiction
I understand that some states restrict the provision of psychotherapy services to clients who are physically located in the state where the clinician is licensed. This may limit the number of sessions available per calendar year for out-of-state clients. My therapist will inform me of any applicable limitations.

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6. Emergencies and Crisis Situations
I understand that telehealth psychotherapy is not appropriate for emergencies or crisis situations. If I am experiencing an emergency or crisis, I agree to call 911 or go to the nearest emergency room or crisis facility.

 

Emergency situations may include, but are not limited to:

• Thoughts of harming myself or others

• Uncontrolled psychotic symptoms

• Life-threatening situations

• Substance use that compromises my safety

If I am experiencing suicidal thoughts, I understand that I should call 911, contact my local county crisis line, or call the National Suicide Hotline at 1-800-784-2433.