Telebehavioral health is the delivery of behavioral health services using interactive technologies (use of audio, video or other electronic communications) between a practitioner and a client/patient who are not in the same physical location. The interactive technologies used in telebehavioral health incorporate network and software security protocols to protect the confidentiality of client/patient information transmitted via any
electronic channel. These protocols include measures to safeguard the data and to aid in protecting against intentional or unintentional corruption.

Software Security Protocols:
Electronic systems used will incorporate network and software security protocols to protect the privacy and security of health information and imaging data, and will include measures to safeguard the data to ensure its integrity against intentional or unintentional corruption.

Benefits & Limitations:
This service is provided by technology (including but not limited to video, phone, text, apps, and email) and may not involve direct face to face communication. There are benefits and limitations to this service.

Technology Requirements:
I will need access to, and familiarity with, the appropriate technology in order to participate in the service provided. Telehealth will not work effectively without wifi and the appropriate bandwidth.

Exchange of Information:
The exchange of information will not be direct and any paperwork exchanged will likely be provided through electronic means or through postal delivery. During my behavioral health consultation, details of my medical history and personal health information may be discussed with myself or other behavioral health care professionals through the use of interactive video, audio or other telecommunications technology.

Local Practitioners:
If a need for direct, in-person services arises, it is my responsibility to schedule an in-person appointment at Ken Starr, or to contact practitioners in my area. I understand I may utilize my primary care
physician if my behavioral practitioner is unavailable. I understand that an opening may not be immediately available in either office.

Self- Termination:
I may decline any telebehavioral health services at any time without jeopardizing my access to future care, services and benefits.

Risks of Technology:
These services rely on technology, which allows for greater convenience in service delivery. There are risks in transmitting information over technology that include, but are not limited to, breaches of confidentiality, theft of personal information, and disruption of service due to technical difficulties.

Modification Plan:
My practitioner and I will regularly reassess the appropriateness of continuing to deliver services to me through the use of the technologies we have agreed upon today, and modify our plan as needed.

Emergency Protocol:
In emergencies, in the event of disruption of service, or for routine or administrative reasons, it may be necessary to communicate by other means, go to the hospital, call 911, or to involve other persons in my support network.

Client Communication:
It is my responsibility to maintain privacy on the client end of communication. Insurance companies, those authorized by the client, and those permitted by law may also have access to records or communications.
I will take the following precautions to ensure that my communications are directed only to my psychologist or other designated individuals on a Release of Information.

Storage:
My communication exchanged with my practitioner will be stored in the following manner:
Kareo/Tebra Electronic Medical Record.

Law & Standards:
The laws and professional standards that apply to in-person behavioral services also apply to telehealth
services. This Document does not replace other agreements, contracts, or documentation of informed consent.