1. This practice uses Telehealth to communicate, assess, and treat patients.

2. Your provider has explained to you how Telehealth technology will be used.

3. You consent to receive Telehealth services.

4. You are ready and able to access and participate in Telehealth services.

5. You have been informed of all other options for receiving the practice’s services.

6. Your privacy will be maintained using HIPAA compliant platforms for all communications.

7. To participate in Telehealth sessions, you as the patient/client will also be

requested to maintain a space of privacy, free from distraction to maximize the time we have together and maintain privacy.

8. If you need additional accommodations, we will discuss these needs and determine the appropriate course of action together, for example, if an interpreter is required.

9. If you are not able to participate in Telehealth visits, a referral will be offered to a local provider who may be able to assist you in a different format.

10. You understand that during your Telehealth visits, artificial intelligence (“AI”) technologies may be utilized to assist your provider in analyzing medical information; to transcribe, document, and summarize Telehealth sessions; to provide clinical decision support to my provider; and to enhance the quality and efficiency of the Telehealth services provided.