1. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine/telehealth services, and that no information obtained in the use of telemedicine/telehealth services which identifies me will disclosed to other entities without my consent.
2. I understand that I have the rights to withhold or withdraw my consent to the use of telemedicine/telehealth in the course of my care at any time, without affecting my right to future care or treatment.
3. I understand that I have the right to inspect all information obtained and recorded in the course of a telemedicine/telehealth interaction, and may receive copies of this information for a reasonable fee.
4. I understand that a variety of alternative methods of medical/health care may be available to me, and that I may choose one or more of these at any time. My doctor/therapist has explained the alternatives to my satisfaction.
5. 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.
6. I understand that insurance coverage of telehealth sessions may differ based on my insurance plan. It is in my best interest to check with my insurance company regarding the coverage.
7. I understand that I am fully responsible for co-payments and deductible amounts, and that I am fully responsible to pay the provider if telehealth/telemedicine sessions are not covered by my insurance company
Patient Consent to the Use of Telehealth/Telemedicine Services
I have read and understand the information provided above regarding telehealth/telemedicine services, have discussed it with my physician/therapist, and all of my questions have been answered to my satisfaction. I hereby give consent for the use of telehealth/telemedicine services in my care. I hereby authorize Arohi Counseling, LLC to use telehealth/telemedicine services during my diagnosis and treatment.
Authorization to disclose or obtain confidential client information
I hereby authorize Arohi Counseling to disclose / obtain protected medical information as described below from the records of:
I understand that:
This authorization may be revoked at any time by writing, except to the extent that information has already been disclosed. If information has already been disclosed in reliance on this authorization revoking it will only prevent further disclosure.
subject to re- disclosure by the individual /organization identified
• Information (except drug and alcohol information) disclosure pursuant to this authorization may be
• Arohi Counseling, LLC and its designee are hereby released from any legal responsibility or liability for disclosure of the specified information.
• The Authorization may include Mental Health, Drug & Alcohol Abuse and or HIV related information.
The information to be disclosed:
*****Check in box next to information you wish to have disclosed.
(Two years from today.)
