Notice to Patients and Consent to Telehealth Services Treatment Agreement

This page is for patients who have a telehealth (video) visit scheduled with one of the Families First providers. (If you don’t have an appointment, please call us at (603) 422-8208 to schedule one. Also, you may want to learn more about our telehealth services or learn how to become a Families First patient.)

The following information applies to telehealth services provided by Greater Seacoast Community Health medical providers, dentists and behavioral health counselors. After reading this information, you will be asked to indicate (through an online acknowledgement or by signing a paper or online form) that you understand the following information:

  1. Telehealth involves the use of an encrypted video application (or via telephone during the COVID19 state of emergency) to communicate with my medical provider, dentist or behavioral health therapist.
  2. Telehealth visits, teledental visits and behavioral health therapy sessions will be done over a HIPPA-compliant audio/video platform (or via telephone during the COVID19 state of emergency). Information and notes from these visits will be stored in the same way as face-face visits or sessions. All patient policies and procedures of Greater Seacoast Community Health continue to apply.
  3. My insurance will be billed as it is during face-to-face visits or sessions. Any copayments associated with my insurance will be billed to me by mail. If my insurance is found to be inactive I am fully financially responsible for the expenses of the visit or session.
  4. I have the right to withhold or withdraw consent at any time without impacting my right to future treatment or risking the loss or withdrawal of any Greater Seacoast Community Health services to which I would otherwise be entitled.
  5. No personally identifiable images or information from the telehealth visit will be disseminated without my written consent.
  6. The laws that protect the confidentiality of my medical information in face-face visits or sessions also apply to telehealth visits. I understand that the information disclosed by me during the course of my visit or therapy session is generally confidential. However, the mandatory reporting exceptions to confidentiality that apply in face-to-face sessions also apply to telehealth.
  7. If during a telehealth visit, my medical or dental provider or therapist suspects that I am at imminent risk for harming myself or others, my provider or therapist is required by law to contact the authorities to ensure safety for myself and others.
  8. It is my responsibility to insure the confidentiality of my visit or session in the environment in which I participate. I further understand that my provider may also elect to reschedule the visit or session.
  9. I understand that there are both risks and benefits associated with telehealth. Benefits may include increased access for those who may be challenged by geographic location, transportation, and/or other barriers. Risks related to telehealth visits include certain limits to confidentiality in electronic communication. These risks include, but are not limited to: 1) the possibility — despite reasonable efforts on the part of my medical provider, dentist or behavioral health therapist — that the video (or telephone) interaction between me and my provider could be interrupted due to technical failures or faulty Internet connection; and 2) the potential for confidentiality breaches due to technical failures. These risks will be offset with the use of Greater Seacoast Community Health’s chosen communications platforms. Furthermore, when using the video platform, the contents of my medical, dental or behavioral health care provider’s computer are encrypted to further ensure my privacy and confidentiality.
  10. The following additional information applies to tele-Behavioral Health visits: 1) Tele-Behavioral Health sessions will follow the same format, timeframes and structure as face-to-face sessions. 2) Though I understand that I may benefit from tele-Behavioral Health therapy, I also understand that results cannot be guaranteed or assured.

ACKNOWLEDGMENT AND ACCEPTANCE

My signature, or my online acknowledgement of consent, indicates that I have read and understand this document and that I give my consent for telehealth services.

Click this link to indicate that you have read and agree to the Telehealth Services Agreement and are ready to check in for your appointment.