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Consent to Treat / Telehealth Informed Consent

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Consent to Evaluate/Treat

I voluntarily consent that I will participate in a psychiatric evaluation and/or treatment by clinicians with Legion Health. I understand that following the evaluation and/or treatment, complete and accurate information will be provided concerning each of the following areas:


a. The benefits of the proposed treatment.

b. Alternative treatment modes and services.

c. How the treatment will be administered.

d. Expected side effects from the treatment and/or the risks of side effects from medications (when applicable).

e. Probable consequences of not receiving treatment.


The evaluation or treatment will be conducted by a Psychiatric Mental Health Nurse Practitioner and will be conducted within the boundaries of Texas Law for Psychiatric services.


Benefits to Evaluation/Treatment:


Evaluation and treatment may be administered with psychiatric interviews, assessments or testing, medication management, as well as expectations regarding the length and frequency of treatment. It may be beneficial to me and the referring professional to understand the nature and cause of any difficulties affecting my daily

functioning, so that appropriate recommendations and treatments may be offered. Uses of this evaluation include diagnosis, evaluation of treatment, estimating prognosis, and education and rehabilitation planning. Possible benefits of treatment include improved cognitive or academic/job performance, health status, quality of life, and awareness of strengths and limitations.


Confidentiality, Harm, and Inquiry:


Information from my evaluation and/or treatment is contained in a confidential electronic

medical record. I consent to disclosure for use by Legion Health providers for the continuity of my care. Per Texas mental health law, the information provided will be kept confidential with the following exceptions:

1. If I am deemed to present a danger to myself or others

2) If concerns about possible abuse or neglect arise

3) If a court order is issued to obtain records.


Right to Withdraw Consent:


I have the right to withdraw my consent for evaluation and/or treatment at any time by providing a written request to the treating clinician. I have read and understand the above, have had an opportunity to ask questions about this information, and I consent to the evaluation and treatment. I also attest that I have the right to consent to treatment. I

understand that I have the right to ask questions of my service provider about the above information at any time.


I understand that my health and wellness provider via Legion Health, PA wants me to participate in a telehealth video consultation.


I, hereby consent to engage in telemedicine as part of my treatment plan. I understand that “telemedicine” includes the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, or data communications. I understand that telemedicine also involves the communication of my medical/behavioral health information, both orally and visually, to health care practitioners located and licensed in the state of Texas.


I understand that I have the following rights concerning telemedicine:


1. I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment nor risking the loss or withdrawal of any program benefits to which I would otherwise be entitled.


2. The laws that protect the confidentiality of my medical information also apply to telemedicine. As such, I understand that the information disclosed to me during my treatment is generally confidential. However, there are both mandatory and permissive expectations 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 behavioral or emotional state an issue in a legal proceeding.


3. I understand that there are risks and consequences from telemedicine, including, but not limited to, the possibility, despite reasonable efforts on the part of my clinician, that: the transmissions of my medical information could be disrupted or distorted by technical failures; the transmission of my medical information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons.


4. In addition, I understand that if my clinician believes I would be better served by another form of service (e.g. face-to-face services) I will be referred to a clinician who can provide such services in my area. Finally, I understand that there are potential risks and benefits associated with any form of psychiatric care and that despite my efforts and the efforts of my clinician, my condition may not be improved, and in some cases may even get worse.


5. I understand that I may benefit from telemedicine, but that results cannot be guaranteed or assured.


6. I understand that I have a right to access my medical information and copies of medical records by Texas law.


I have read and understand the information provided above. 

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