SCOTTSDALE BEHAVIORAL HEALTH Telepsychiatry Informed Consent Patient Name: ________________________________________ Date of Birth:____________ Location of Patient: ___________________________________________________________ Introduction Telepsychiatry is the form of telemedicine that allows patients to access psychiatirc care using audio-video interface such as videoconferencing. Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption. Expected Benefits: Improved access to psychiatric care by enabling a patient to remain in his/her home or office. More efficient psychiatric evaluation and management. Obtaining expertise of a distant specialist. Possible Risks: As with any medical procedure, there are potential risks associated with the use of telepsychiatry. These risks include, but may not be limited to: In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the physician and consultant(s); Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment; In very rare instances, security protocols fail, causing a breach of privacy of personal medical information; In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgmental errors; Please initial after reading this page: __________
SCOTTSDALE BEHAVIORAL HEALTH Telepsychiatry Informed Consent Patient Name: ________________________________________ Date of Birth:____________ Location of Patient: ___________________________________________________________ Introduction Telepsychiatry is the form of telemedicine that allows patients to access psychiatirc care using audio-video interface such as videoconferencing. Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption. Expected Benefits: Improved access to psychiatric care by enabling a patient to remain in his/her home or office. More efficient psychiatric evaluation and management. Obtaining expertise of a distant specialist. Possible Risks: As with any medical procedure, there are potential risks associated with the use of telepsychiatry. These risks include, but may not be limited to: In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the physician and consultant(s); Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment; In very rare instances, security protocols fail, causing a breach of privacy of personal medical information; In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgmental errors; Please initial after reading this page: __________