: This form is to obtain your consent to participate in telehealth sessions with Lisha Song, LMHC (from here on referred to as “health care provider”).
As an alternative to in office visits, telemedicine/telehealth sessions are available. These are live/real time interactions on a HIPPA compliant, video-conferencing platform that provides a two-way audiovisual link between a client and a health care provider. According to the WAC 182-531-1730, approved physical locations of the client at the time of the healthcare service includes “home or any location determined appropriate by the individual receiving the service”.
Please read the following and sign to acknowledge your understanding and agreement.
. I am responsible for verifying insurance coverage for telehealth (assuming medical necessity) on my specific plan, with Lisha Song, LMHC license # LH00011204.
. There are no circumstances where there will be other personnel present.
. I will inform my health care provider if others are present during my video session.
. There will be no audio, photo or video recordings of my telehealth session.
. Telehealth with this health care provider, does not include email or any other electronic transmissions, besides my scheduled video session.
. Scheduling may be communicated via email or text with this healthcare provider.
. If I haven’t made prior payment arrangements, I will make my payment via PayPal: email@example.com
prior to checking in to the virtual waiting room.
. On the day of my appointment and a few minutes before my appointment time, I will check my email for an invitation link to my telehealth video session, which will be held via Zoom.com. This platform is HIPPA compliant.
. My health care provider will keep written notes of sessions and store them with the same procedures as in office visits.
. All confidentiality rights and protections under federal and Washington state law apply.
. As with any health care service, there are risks associated with the use of telehealth, including equipment failure, poor image resolution and information security issues.
. Noting the above, I understand that my participation in telehealth is voluntary and I have the right to withdraw consent to telehealth at any time without affecting my right to future care.
I agree to participate in telehealth video sessions via Zoom.com.