Telehealth Consent Form

All Walks of Life, LLC provides services using interactive video conferencing tools, such as ZOOM, FaceTime, or Skype. Potential risks include, but may not be limited to: information transmitted may not be sufficient (poor resolution of video); delays in medical evaluation and treatment due to deficiencies or failures of the equipment; security protocols can fail, causing a breach of privacy; and a lack of access to all the information available in a face-to-face visit may result in errors in medical judgment. Alternative to telehealth include traditional face-to-face sessions.  

Your Rights:  

1. To understand that the laws that protect my privacy and confidentiality of medical information also apply to telehealth;  
2. To understand that the ZOOM, FaceTime, and Skype are known to incorporate network and software security protocols to protect the confidentiality of information and audio/visual data. These protocols help safeguard data and aid in protecting against intentional or unintentional corruption;
3. To withdraw my consent to the use of telehealth at any time;
4. (Your practitioner has the right) to withdraw consent for the use of telehealth during the course of my care at any time; and
5. I understand that all rules and regulations that apply to clinical practice in the state of Maryland also apply to telehealth. 

 Your Responsibilities:  

1. I will not record any telehealth sessions without the prior written consent of All Walks of Life. I understand that All Walks of Life or the agency’s practitioners will not record telehealth sessions without my consent;  
2. I will inform the practitioner if any other person can hear or see any part of our session before the session begins. Likewise, the practitioner will inform me if any other person can hear or see any part of the session before the session begins.
3. I understand that I MUST be a resident of Maryland to be eligible for telehealth services from All Walks of Life, LLC.

Your Signature:  

Submitting the form below acts as your electronic signature. Completeing the form and submitting it through the AWL website indicates that you have read and understand the information provided above regarding telehealth, and that you authorize All Walks of Life, LLC to use telehealth in the course of diagnosis and treatment.