Telehealth/Technology Waiver

TELEHEALTH/TECHNOLOGY WAIVER

 

Communication by Email, Text Message, or Video Conferencing

 

It may become useful during the course of your treatment to communicate or utilize technology to communicate. Some of these methods may or may not be confidential in their typical form.  At the present time ADAPT Inc. utilizes Web Ex Conferencing systems and has been assured that their conferencing systems meet the criteria to maintain confidentiality according federal statute 42 CFR, Part 2.  At no time will identifying, personal or private information be stored within the Web Ex system. 

 

As a policy practice, we work hard to ensure that all communication with patients and/or their families via technology is secure and does not provide identifying information.

 

 

CONSENT FOR TRANMISSION OF PROTECTED HEALTH/ADDICTION INFORMATION BY SECURE/NON-SECURE MEANS

 

I consent to allow ADAPT, Inc. to use secure/non-secure technology to transmit to me protected health information:

 

• Information related to scheduling of meetings and appointments

• Information related to referral sources and payments

• Information related to evaluation, assessment, and programming

 

I have been informed of the risk, including but not limited to my confidentiality in services/treatment, of transmitting my protected health/addiction information by secured/unsecured means.