Utah Department of Human Services 3rd Party Telehealth AgreementTelehealth Agreement • October 1st, 2018
First Name Middle Initial Last Name Utah-IDThis is the username used to login into utah.gov systems, NOT the email address. Work Email AddressThe email address used to create your Utah-ID must be your work/organizational email. Work Phone Number Provider/Agency Name Davis Behavioral Health, Inc. Request Date
Agreement for TelehealthTelehealth Agreement • March 16th, 2020
Variously dubbed telemedicine, teletherapy, distance therapy, e-therapy, internet therapy, or online therapy, “telehealth” is defined as the use of electronic transmission to provide interactive real-time mental health services remotely, including consultation, assessment, diagnosis, treatment planning, counseling, psychotherapy, coaching, guidance, education and transfer of medical information with an experienced psychotherapist. This can include both video and audio forms of communication, via the internet or telephone. Telehealth services do not include texting or e-mail.
Email FormTelehealth Agreement • December 15th, 2020
COVID-19 has impacted the daily lives of all Californians. The latest direction from the Department of Health Care Services (DHCS) allows for the provision of temporary Remote Client Services also known as Telehealth.
ContractTelehealth Agreement • September 9th, 2020
This Agreement is in respect of the provision of TELEHEALTH SERVICES ONLY as the mode of delivery is different from a face to face appointment and is in addition to the consent form you read and signed when you commenced as a client at The Relationspace. You previously agreed to the terms and conditions of services provided by The Relationspace in respect of fees and cancellations, contact with the practitioner and the protection and disclosure of your personal information only in situations where required by law and those terms are still in effect.
ContractTelehealth Agreement • March 15th, 2020
GPT Physical Therapy Telehealth AgreementTelehealth Agreement • March 25th, 2020
In response to the Covid-19 pandemic, GPT Greenwood Physical Therapy is offering the option of telemedicine to our patients. Telemedicine, defined by WAC 182-531-1730, is when a PT uses video communications to deliver services to a client at a site remote to the provider. This is an amazing way to have PT, even when face to face contact is not possible.
Agreement for Telehealth & InstructionsTelehealth Agreement • March 19th, 2020
The Digital Age continues to facilitate new ways to assist people to meet their mental health needs. We are happy to move in step with technological advancements and provide telehealth services. As part of our commitment to your well-being and safety, some guidelines are necessary. Please review this carefully.
TELEHEALTH VIA VIDEO CONFERENCING AGREEMENTTelehealth Agreement • August 13th, 2020
treatment delivery to occur via interactive video-conferencing (i.e., virtual “face-to-face” sessions) in lieu of, or in addition to, “in-person” sessions. Video conferencing (VC) is a real-time interactive audio and visual technology that enables our clinicians to provide mental health services remotely. You will not have to purchase a plan or provide your name when you “join” our online meeting. Treatment delivery via VC may be a
Debra Kessler, Psy.D., R.N., M.N. (818) 248-6414Telehealth Agreement • March 16th, 2020
The Digital Age continues to facilitate new ways to assist people to meet their mental health needs. We are happy to move in step with technological advancements and provide telehealth services. As part of our commitment to your well-being and safety, some guidelines are necessary. Please review this carefully.
REQUEST TO USE, PASSIVE CONSENT, AND AGREEMENT REGARDING USE OF TELEHEALTHTelehealth Agreement • September 30th, 2020
During the 2020-2021 school year, the Auburn Enlarged City School District (the “District”) will utilize Telehealth to provide services to your child. Telehealth is defined as any service that is provided remotely that would typically be delivered in person (i.e. academic advising, career planning, individual counseling, small group sessions, speech therapy, occupational therapy, physical therapy, evaluations, etc.). Telehealth can be used only if you execute this Passive Consent and Agreement outlined below permitting us to provide services to your child in emergency and non-emergency situations.
P h: 0410 450220 louise@louiseosullivan.com.auTelehealth Agreement • October 21st, 2020
This Agreement is in respect of the provision of TELEHEALTH SERVICES ONLY. It is an addition to the consent form you read and signed upon commencement as a client. You previously agreed to the terms and conditions of services provided, in respect to fees and cancellations, contact with the practitioner and the protection and disclosure of your personal information only in situations where required by law and those terms are still in effect.
Melissa Gressner, PsyD Licensed Clinical Psychologist 1807 S Pearl StreetTelehealth Agreement • June 19th, 2024
This contract indicates my consent for distance-oriented behavioral health sessions, otherwise known as telehealth, which take place over a HIPPA compliant telehealth platform known as Doxy.me.
Accepted ManuscriptTelehealth Agreement • October 2nd, 2018
Agreement between telehealth and in-person assessment of patients with chronic musculoskeletal conditions presenting to an advanced-practice physiotherapy screening clinic
Telehealth AgreementTelehealth Agreement • October 26th, 2021
PAWC Telehealth AgreementTelehealth Agreement • August 3rd, 2018
telehealth services at PAWC. Should you have any questions about this agreement you may discuss them with your provider at the first appointment or you may contact the administrative staff who can answer general questions (415) 237-0377.
AGREEMENT TO TELEHEALTH:Telehealth Agreement • August 28th, 2020
ContractTelehealth Agreement • March 30th, 2020
By signing this agreement I understand that a medical exam and treatment will be provided through an interactive video connection. Electronic systems used will incorporate network and security protocols to protect the confidentiality of patient identification. No recording of the visit will be done but the visit will be documented in the medical record in the same manner in which all visits are documented in the record.
ContractTelehealth Agreement • May 9th, 2024 • Alabama
This Agreement is effective this day of , 2024, (“Effective Date”) and is between The Children’s Hospital of Alabama (“Children’s”), an Alabama private nonprofit corporation and
TELEMENTAL HEALTH VIA VIDEO CONFERENCING AGREEMENTTelehealth Agreement • April 30th, 2020
delivery to occur via interactive video-conferencing (i.e., virtual “face-to-face” sessions) in lieu of, or in addition to, “in-person” sessions. Video conferencing (VC) is a real-time interactive audio and visual technology that enables our clinicians to provide mental health services remotely. The VC system we use (www.zoom.us) meets HIPAA standards for encryption and privacy protection but we cannot guarantee privacy. You will not have to purchase a plan or provide your name when you “join” our online meeting.
TELEHEALTH AGREEMENTTelehealth Agreement • October 29th, 2021
Telehealth sessions are similar to in-person sessions in many ways, including your rights to confidentiality, the scheduling of appointments, ways you may contact me between sessions, and session fees. Telehealth sessions enable me to provide mental health services, including Cognitive Behavioral Therapy for Insomnia (CBT-I), remotely. Although fees are the same for in-person and telehealth sessions, I cannot guarantee that your insurance coverage will be the same. In some cases, telehealth coverage is the same as in-person coverage, but in some cases it is not. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc.
Telehealth AgreementTelehealth Agreement • October 26th, 2021
Client/Patient Telehealth Agreement with Waterstone Counseling CentersTelehealth Agreement • December 30th, 2021
Telehealth allows my doctor and/or therapist to diagnose, consult, treat and educate using interactive audio, video or data communication regarding my treatment. I hereby consent to participating in medical treatment and/or psychotherapy via a HIPPA compliant web platform (hereinafter referred to as Telehealth). I understand I have the following rights under this agreement:
ContractTelehealth Agreement • March 3rd, 2020 • Alabama
This Agreement is effective , , 2020, (“Effective Date”) and is between The Children’s Hospital of Alabama (“Children’s”), an Alabama private nonprofit corporation and
TELEHEALTH VIA VIDEO CONFERENCING AGREEMENTTelehealth Agreement • March 12th, 2020
After intake and the establishment of a therapeutic relationship, it may be possible for treatment delivery to occur via interactive video-conferencing (i.e., virtual “face to face” sessions) in lieu of, or in addition to, “in-person” sessions. Video conferencing (VC) is a real-time interactive audio and visual technology that enable our clinician to provide mental health services remotely. The VC system we use meets HIPAA standards of encryption and privacy protection but we cannot guarantee privacy. You will not have to purchase a plan or provide your name when you “join” our online meeting. Treatment delivery via VC may be a preferred method due to convenience, distance, or other circumstances. Although VC may be used when the clinician and client are in different locations, licensure regulations only allow a session to be conducted in the state in which the clinician is licensed and the client is located. An occasional exception can be made if temporary permission is available from
Cornerstone Behavioral Healthcare Telehealth Agreement & Signature PageTelehealth Agreement • January 13th, 2020
I, _____________________________________________, agree to participate in Telehealth services. These services will be provided by, _______________________________________. My signature acknowledges that I have read, understood and agree to the Telehealth Service Policy (page 2) that governs services provided at Cornerstone Behavioral Healthcare.
TeleHealth Agreement for List BillingTelehealth Agreement • January 10th, 2019
TBA Member Insurance Solutions (TBAMS) will email a list bill to the employer on or about the 20th of each month. Any changes (additions or cancellations) need to be reported to TBAMS before the 1st of the month. The payment of the adjusted invoice will be deducted from your checking account on the 2nd working day of each month. Employer will not pay for any employee cancelled before the last business day of each month. Conversely, a credit will not be allowed for any reason if the employee is not cancelled before the last business day of each month.
Melissa Gressner, PsyD Licensed Clinical Psychologist 1855 S. Pearl Street, Ste., #10Telehealth Agreement • January 6th, 2022
This contract indicates my consent for distance-oriented behavioral health sessions, otherwise known as telehealth, which take place over a HIPPA compliant telehealth platform known as Doxy.me.
Telehealth Agreement & Signature PageTelehealth Agreement • October 5th, 2021
TELEHEALTH VIA VIDEO CONFERENCING AGREEMENTTelehealth Agreement • April 19th, 2016
After intake and the establishment of a therapeutic relationship, it may be possible for treatment delivery to occur via interactive video-conferencing (i.e., virtual “face-to-face” sessions) in lieu of, or in addition to, “in-person” sessions. Video conferencing (VC) is a real time interactive audio and visual technology that enables our clinicians to provide mental health services remotely. The VC system I use (https://vsee.com) meets HIPAA standards of encryption and privacy protection but cannot guarantee privacy. You will not have to purchase a plan or provide your name when you “join” an online meeting. Treatment delivery via VC may be a preferred method due to convenience, distance, or other circumstances. Although VC may be used when the clinician and client are in different locations, licensure regulations only allow a session to be conducted in the state in which the clinician is licensed. An occasional exception can be made if temporary permission is available from another s
TELEHEALTH AGREEMENTTelehealth Agreement • July 20th, 2020
As a client receiving mental health services through telehealth methods, I understand that such service is provided by technology (including but not limited to video, phone, text, and email) and may or may not involve direct, face to face, communication.
TELEHEALTH AGREEMENTTelehealth Agreement • March 23rd, 2020
Telehealth sessions are similar to in-person sessions in many ways, including your rights to confidentiality, the scheduling of appointments, ways you may contact me between sessions, and session fees. Telehealth sessions enable me to provide mental health services, including Cognitive Behavioral Therapy for Insomnia (CBT-I), remotely. Although fees are the same for in-person and telehealth sessions, I cannot guarantee that your insurance coverage will be the same. In some cases, telehealth coverage is the same as in-person coverage, but in some cases it is not. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc.
TELEHEALTH VIA VIDEO CONFERENCING AGREEMENTTelehealth Agreement • July 28th, 2020
This agreement discusses the benefits and risks of undergoing treatment using telehealth as a modality for psychotherapy. We will use that modality if we decide that the benefits outweigh the risks in your particular case, as part of establishing your treatment plan. The system I use (https://doxy.me/drlberman) meets HIPAA standards of encryption and privacy protection but I cannot guarantee privacy. You will not have to purchase a plan when you “join” our online meeting.
TeleHealth Agreement for List BillingTelehealth Agreement • January 11th, 2019
The TDA Insurance Agency, Inc. will email a list bill to the employer on or about the 20th of each month. Any changes (additions or cancellations) need to be reported to TDA Insurance before the 1st of the month. The payment of the adjusted invoice will be deducted from your checking account on the 2nd working day of each month. Employer will not pay for any employee cancelled before the last business day of each month. Conversely, a credit will not be allowed for any reason if the employee is not cancelled before the last business day of each month.
Oregon extends telehealth agreement for health insurance plansTelehealth Agreement • December 18th, 2020
The State of Oregon has reached an agreement with several health insurance companies to continue providing expanded telehealth options through at least June 30, 2021.
agreement to continue care via telehealth.Telehealth Agreement • February 2nd, 2021
