Telehealth Informed Consent

Telehealth services offered by Great Lakes Psychology Group and Great Lakes Psychology Group’s engaged providers (our “providers”) will include the practice of psychological health care delivery, consultation, diagnosis, treatment, referral to resources, education and recommendation (the “Service”). The Services provided may also include chart review, health information sharing, and non-clinical services, such as patient education. The information you provide may be used for diagnosis, therapy, follow-up and/or patient education, and may include any combination of the following: (1) a review of health records, and/or test results via asynchronous communications; (2) live two-way interactive audio and video; (3) interactive audio with store and forward; or (4) output data from medical devices and sound and video files. The electronic communication systems we use will incorporate network and software security protocols to protect the confidentiality of patient identification and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

Your provider typically provides telehealth services using the following tool: Zoom Video Conferencing for Telehealth

• Improved access to care by enabling you to remain in your home while the Great Lakes Psychology Group provider provides psychotherapy services at distant/other sites.
• More efficient psychological health care delivery, evaluation and management.
• Obtaining expertise of a specialist as appropriate.

• Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment and technologies.
• In rare events, the provider may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled telehealth session or a referral to a local psychologist or counselor as applicable.
• In very rare events, security protocols could fail, causing a breach of privacy of personal health information.

If you need to receive follow-up care, please contact your Great Lakes Psychology Group provider. In the event of an inability to communicate as a result of a technological or equipment failure, please contact Great Lakes Psychology Group at 800-693-1916 and support@glpg.net.

• Our providers do not address urgent cases or medical emergencies. If you believe you are experiencing a medical emergency, you should dial 9-1-1 and/or go to the nearest urgent care center or emergency room. After receiving urgent healthcare treatment, you should visit your primary care doctor.
• Our providers are an addition to, and not a replacement for, your primary care physician. Responsibility for your overall medical care should remain with your local primary care doctor, if you have one, and we strongly encourage you to locate one if you do not.
• If your provider believes you would be better served by another form of psychotherapeutic service (e.g. face-to-face service), you will be referred to a psychotherapist in your area who can provide such service.

By checking the box associated with “Informed Consent”, you acknowledge that you understand and agree with the following:

1. I hereby consent to receiving Great Lakes Psychology Group’s services via telehealth technologies. I understand that Great Lakes Psychology Group and its providers offer telehealth-based psychotherapy services, but that these services do not replace the relationship between me and my primary care doctor. I also understand it is up to the Great Lakes Psychology Group provider to determine whether or not my specific clinical needs are appropriate for a telehealth encounter.
2. I have been given an opportunity to select a provider from Great Lakes Psychology prior to the consult, including a review of the provider’s credentials.
3. I understand that federal and state law requires health care providers to protect the privacy and the security of health information. I understand that Great Lakes Psychology Group will take steps to make sure that my health information is not seen by anyone who should not see it. I understand that telehealth may involve electronic communication of my personal health information to other health practitioners who may be located in other areas, including out of state.
4. I understand there is a risk of technical failures during the telehealth encounter beyond the control of Great Lakes Psychology Group. I agree to hold harmless Great Lakes Psychology Group for delays in evaluation or for information lost due to such technical failures.
5. I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment. I understand that I may suspend or terminate use of the telehealth services at any time for any reason or for no reason. I understand that if I am experiencing a medical emergency, that I will be directed to dial 9-1-1 immediately and that the Great Lakes Psychology Group providers are not able to connect me directly to any local emergency services.
6. I understand that alternatives to telehealth consultation, such as in-person services, are available to me, and in choosing to participate in a telehealth consultation, I understand that some parts of the services involving tests or assessments may be conducted by individuals at my location, or at a testing facility, at the direction of the Great Lakes Psychology Group provider.
7. I understand that I may expect the anticipated benefits from the use of telehealth in my care, but that no results can be guaranteed or assured.
8. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Persons may be present during the session other than the Great Lakes Psychology Group provider in order to operate the telehealth technologies. I further understand that I will be informed of their presence in the session and thus will have the right to request the following: (1) omit specific details of my psychological health history that are personally sensitive to me; (2) ask non-clinical/licensed personnel to leave the telehealth session; and/or (3) terminate the session at any time.
9. I understand that Great Lakes Psychology Group does not provide psychiatric health care and that I will not be given a prescription at all.I understand that if I participate in a session, that I have the right to request a copy of my medical records which will be provided to me at reasonable cost of preparation, shipping and delivery.
10. I understand that if I participate in a session, that I have the right to request a copy of my medical records which will be provided to me at reasonable cost of preparation, shipping and delivery.

I have read this document carefully, and understand the risks and benefits of the telehealth session and have had my questions regarding the session explained and I hereby give my informed consent to participate in a telehealth session under the terms described herein.