Tele-Health Connection Agreement

I understand the purpose of tele-health services I have chosen to receive the service at an appropriate location which is confidential. I agree to receive Tele-health services via my personal equipment including mobile devices and computers.

- I understand that I am responsible for any confidentiality of my equipment and location during tele health sessions.
- I understand I must have reliable, high speed internet access to engage in telehealth services.
- I will provide my own reliable equipment for telehealth session that provides clear visual and auditory capabilities to be both seen and heard during all telehealth sessions.
- I understand I will be required to download the appropriate app on my phone/computer/electronic devise such as V-See account.
- I understand I cannot be driving a vehicle while engaging in telehealth session.
- I understand I am responsible for locating a private area while in session.
- I understand the telehealth connection is only used during scheduled session with the provider.
- I understand the session will not be recorded by either party, unless I have given consent and signed a Videotaping Authorization form.
- I understand I may withdraw from this service at any time without affecting my right of future care or treatment.

I have been advised of all the potential risks, consequences and benefits of Tele-Health. I have had an opportunity to ask questions about the information and all of my questions have been answered. I understand the written information provided above.