AGREEMENT FOR TELEHEALTH SERVICESTelehealth Services Agreement • September 14th, 2022 • Louisiana
THIS AGREEMENT FOR TELEHEALTH SERVICES (the “Agreement”) is made and entered into this _ (the “Effective Date”) by and between Natchitoches Parish Hospital Service District No. 1 d/b/a Natchitoches Regional Medical Center (“NRMC”) and Natchitoches Parish School Board (“CLIENT”). (NRMC and CLIENT are each a “Party,” and collectively the “Parties”).
Agreement (Consent) to Use Telehealth ServicesTelehealth Services Agreement • April 6th, 2020
I, , agree (consent) to receive psychological treatment over the telephone and/or computer from Providence Health & Services (Providence). This method of providing care is called “telehealth”.
Agreement for Telehealth ServicesTelehealth Services Agreement • April 2nd, 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 to provide telehealth services. As part of our commitment to your well-being and safety, a few guidelines should be discussed. Please read this form carefully.
CLIENT TELEHEALTH SERVICES AGREEMENTTelehealth Services Agreement • February 18th, 2021 • Maryland
This CLIENT TELEHEALTH SERVICES AGREEMENT (this “Agreement”) is made effective as of _________________ (the “Effective Date”), by and between BREAKTHROUGH COUNSELING SERVICES, LLC, a Maryland limited liability company (“BCS”), and ______________________________ who resides at _________________________________ (hereafter, the “Client”).
Agreement for Telehealth ServicesTelehealth Services Agreement • May 7th, 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.
ContractTelehealth Services Agreement • September 24th, 2020
THIS TELEHEALTH SERVICES AGREEMENT (hereinafter referred to as this “Agreement”), is made and entered into on this date: (the “Effective
Date: To: Potential/Current Client of Catholic Charities ND From: Catholic Charities ND, Counseling Department Re: Telehealth Services AgreementTelehealth Services Agreement • May 21st, 2020
Catholic Charities ND offers many client’s the option of receiving psychotherapy services using technology (i.e. phone and/or video calls). Please note that while you choose this option, there may be times you are requested to attend a session in the office. This request will be made when it’s felt necessary to maintain a high quality of care and address your therapeutic goals in the most appropriate, effective manner. While many clients enjoy and benefit from receiving psychotherapy services from a distance, you should be aware of possible limitations.
ContractTelehealth Services Agreement • December 9th, 2020
To: Potential/Current Client of Catholic Charities ND From: Catholic Charities ND, Counseling Department Re: Telehealth Services Agreement
ContractTelehealth Services Agreement • April 29th, 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 to provide telehealth services. As part of our commitment to your well-being and safety, a few guidelines should be discussed. Please read this carefully.
Cal. Health & Safety Code § 1374.14.]Telehealth Services Agreement • January 28th, 2021
Compassion Pediatrics Behavioral Health Telehealth Services Agreement and PoliciesTelehealth Services Agreement • April 24th, 2024
Depending on the availability of service professionals, Compassion BHS may offer to provide service to me through a Telehealth audio and/or videoconference. I understand that Telehealth services are delivered through a secure transmission and that Compassion BHS will make every effort to ensure that all information regarding my Telehealth encounter is kept safe and private. I understand that if I am uncomfortable with the use of audio and/or videoconferencing technology, at any time, I may stop the video/audio conference and request that a traditional, in- person clinical visit be scheduled. I understand that all laws regarding the privacy and security of my Personal Health Information (PHI) as outlined by HIPAA, apply to Telehealth services as they do to all other applicable services delivered by Compassion BHS. I understand that I am not under obligation to receive services only by Telehealth, and that I can choose to receive traditional in-person services instead. In case of emergen
TELEHEALTH SERVICES AGREEMENTTelehealth Services Agreement • July 10th, 2020 • Tennessee
This Telehealth Services Agreement (the “Agreement”) by and between BLUE RIDGE MEDICAL MANAGEMENT CORPORATION d/b/a Niswonger Virtual Health, a Tennessee corporation (“BRMMC”) and City of Kingsport, for its Kingsport City Schools (“District”) shall be effective as of August 1, 2020 (the “Effective Date”). BRMMC and District shall be referred to herein each as a “Party” and collectively as the “Parties.”
AGREEMENT By and BetweenTelehealth Services Agreement • November 11th, 2022 • Florida
This Agreement (“Agreement”) is made by and between The School Board of Orange County, Florida, a political subdivision of the State of Florida, located at 445 West Amelia Street, Orlando, FL 32801, (hereinafter referred to interchangeably as “Orange County Public Schools”, “OCPS”, “Board”, “School Board”, or “District”), and Hazel Health, Inc., whose business address is 118 Second Street, Floor 6, San Francisco, CA 94105 (hereinafter referred to as “Contractor”). Each entity shall be referred to individually as a “Party” and collectively as, the “Parties.”
Agreement for Telehealth ServicesTelehealth Services Agreement • January 14th, 2021
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 to provide telehealth services. As part of our commitment to your well-being and safety, a few guidelines should be discussed. Please read this carefully
Agreement for Telehealth ServicesTelehealth Services Agreement • May 8th, 2021
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.
Consent for Payment of ServicesTelehealth Services Agreement • March 26th, 2020
This Agreement for Telehealth Services (“Agreement”) is a temporary execution of services effective as of , 20 (“Effective Date”) by and between Integrated Care Concepts & Consultation, and, (“Clinician”), and
This form describes GIC STEP’s telehealth service agreement and includes:Telehealth Services Agreement • August 20th, 2021
By signing my name on this document, I understand and agree that I am signing this Consent and that I have reviewed, understand and accept the risks and benefits of telehealth services as described below and wish to receive such services.
Agreement for Telehealth ServicesTelehealth Services Agreement • March 21st, 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 to provide telehealth services. As part of our commitment to your well-being and safety, a few guidelines should be discussed. Please read this carefully.
TELEHEALTH SERVICES - SERVICE & PAYMENT AGREEMENTTelehealth Services Agreement • March 16th, 2020
TeleHealth virtual consultation services offered by Eze Health Center are provided as an alternative way for established patients to correspond with the medical provider, via online correspondence, without requirement of an in-office visit. This is a HIPAA-compliant “office visit” for patients.
Disclosure Statement & Agreement for Telehealth ServicesTelehealth Services Agreement • March 17th, 2020
I, , understand Telehealth involves the use of electronic communications between my therapist, who is employed at Building Foundations Counseling Center, Inc. A Professional Family Counseling Corporation, and myself, who are different locations to conduct a live two-way audio and video session.
TELEHEALTH SERVICES AGREEMENTTelehealth Services Agreement • January 15th, 2021 • Delaware
System & Software Maintaining and operating hardware and software, including tech support for patients and clinical staff. CPT 99454. BlueStar BlueStar BlueStar
AGREEMENT TO RECEIVE TELEHEALTH SERVICESTelehealth Services Agreement • April 9th, 2020
