Telemedicine Consent Form

I do hereby authorize James Yi, MD-PhD and any other providers working for (or prescribing for) Blue Bell Psychiatry to conduct my sessions using Telemedicine.

Telemedicine sessions are similar to routine outpatient office visits, except interactive video technology is used to communicate with your provider at a distance. Just like with in office visits, your provider will perform clinical interview including safety assessment and make treatment recommendations.

• I understand that the Telemedicine platform allows access to mental health services that might not otherwise be available due to physical health, geographic limitations or other factors. I understand that it is up to the Blue Bell Psychiatry provider’s discretion to determine whether I or my child would be eligible to participate in and benefit from Telemedicine services.
• I understand that Telemedicine appointments are considered outpatient services and are not intended as a substitute for emergency or crisis services. Crisis or mental health emergencies should be directed to the local crisis line or by dialing 911.
• I understand that I will need to download an application and/or software to use this service. I also need to have a broadband Internet connection or a smart phone device with a good cellular connection at home or at the location deemed appropriate for services. I also understand that in case of technology failure, I may contact my provider at Blue Bell Psychiatry via phone to coordinate alternative methods of treatment.
• I understand that all existing laws regarding my access to medical information and copies of my medical records apply to the telemedicine services. Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with the telemedicine services. The laws that protect the confidentiality of my medical information also apply to the telemedicine services. As such, I understand that the information disclosed by me during the course of my therapy is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality including, but not limited to: Reporting child, elder, and dependent adult abuse; Expressed threats of violence towards an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding. Telemedicine platform used by Blue Bell Psychiatry providers is HIPAA compliant to protect my privacy and confidentiality.
• I understand that there are risks and consequences associated with telemedicine including, but not limited to the possibility, despite reasonable efforts on the part of my provider, that the transmission of my medical information could be disrupted or distorted by technical failures. I understand that telemedicine-based services and care may not be as complete as face-to-face services. I understand that I may benefit from telemedicine, but that results cannot be guaranteed or assured. I understand that my provider at Blue Bell Psychiatry cannot provide telemedicine services to me if I am outside of the State of Pennsylvania.
• I understand that I am responsible for fees associated with telemedicine services, which are equal to the corresponding fees associated with face-to-face services. I understand that the fees associated with telemedicine appointments are payable by credit or debit card only. I agree to provide my credit/debit card information and have it on file with Blue Bell Psychiatry. My card will be billed the same day as my scheduled telemedicine appointment. If my card is declined, I agree to provide alternative card information to my provider immediately after my telemedicine session.
• I understand that scheduling is based on my provider’s regular office hours. 24-hour cancellation is required for all telemedicine appointments. I understand that I will be charged in accordance with the cancelation policy for all no-shows and late cancellations.
• As a general practice, Blue Bell Psychiatry DOES NOT record Telemedicine sessions without prior permission.

My signature below indicates that I have read and understand the information provided above. I have discussed all the potential risks, consequences and benefits of telemedicine with my provider and all of my questions have been answered to my satisfaction.