Consent for Telehealth

For your convenience you may complete forms in our office or electronically online.

Effective Living Center (ELC) offers telehealth services using an approved, HIPAA-compliant, Zoom platform. This platform complies with Minnesota State Statutes and Center for Medicare and Medicaid Services (CMS) guidelines for telehealth services. The telehealth service model allows for the delivery of Mental Health Services (assessments and individual therapy) and Substance Use Assessments and/or individual substance use sessions. There may be times when your groups are held via zoom, but you will be notified of this if it should occur.

Telehealth services are offered to clients who are determined to be appropriate for telehealth services; have a barrier that prevent the client and the provider from meeting in the same physical location, who have access to a compatible electronic device (computer, phone, tablet) with internet connection with both audio and visual capabilities; and who agree to download the video conferencing software “Zoom” on their device.

1. Purpose and Benefits: The purpose and benefit of telehealth visits is to provide more timely access to services. In addition to providing the clients convenience and timeliness to scheduling.
2. Client Safety OR Crisis management and interventions: Before engaging in telehealth services, we will develop an emergency response plan to address potential crisis situations that may arise during our telehealth work. We will need to have the address of your physical location and phone number. In the case of a mental health or psychiatric emergency during a telehealth session, where a client is deemed at imminent risk of harming themselves or someone else, ELC staff will contact the client’s local emergency services, crisis response team, and/ or 911.
3. Medical Information and Records: All existing laws regarding your access to medical information and copies of your medical records apply to telehealth services. Record requests or referrals for sending records to other agencies, such as probation offices, social services, attorneys’, other treatment, or medical facilities etc. can only be processed with a valid written Release of Information (ROI).
4. Confidentiality: Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with the telehealth service. All existing confidentiality protections under federal and Minnesota states law apply to information disclosed during the telehealth visit.
5. Risks and Consequences: The telehealth service will be like a routine Mental Health/Substance use office visit, except with interactive video technology which will allow you to communicate with a provider at a distance. I understand that there are risks and consequences associated with telehealth, including but not limited to, disruption of transmission by technology failures, interruption and/or breaches of confidentiality by unauthorized persons, privacy, and/or limited ability to respond to emergencies. We will take reasonable steps to ensure your privacy. But it is important for you to make sure you find a private place for our session where you will not be interrupted.
6. Rights: You may withhold or withdraw your consent to telehealth services at any time without affecting your right of future care or treatment for ELC services.
7. Technical Difficulties: I understand that during a telehealth session, we could encounter technical difficulties resulting in service interruptions. If this occurs, end and restart the session. If we are unable to reconnect within ten minutes, please call our office, St. Cloud 320-259-5381, or Little Falls at 320-632-3166 to discuss the issue as we may have to re-schedule.
8. Appropriateness of Telehealth services: It may be determined that telehealth services are no longer the most appropriate form of treatment for you. If this occurs, we will discuss other options such as in-person services with you.

Authorization: I have been advised of all the benefits, potential risks, and consequences of telehealth. I have had an opportunity to ask questions about this service and all my questions have been answered. I understand the written information provided above.

Text Reminder Consent/Disclaimer: By enrolling in text appointment confirmations, you are authorizing ELC to send text appointment reminders to you on your provided cell phone number. Text message charges from your cell phone provider may apply. By opting into our text message system, you are providing consent to use personal information to provide text appointment reminders/confirmation for the services available by ELC. The text messaging system is provided by ELC to our clients on an as-is basis. Included in the reminder may be information such as the agency name, your name, your provider and appointment dates and times. ELC is not liable for any delays that may be experienced during the transmission of any messages, as delivery is based on the speed and effectiveness of your wireless provider. I authorize ELC to send appointment reminders via text for the client named above.