The following information is MPC’s Telehealth Informed Consent. By consenting to receive telehealth services, you understand and agree to the following:

1. I understand that at the beginning of each Telehealth session, my telehealth provider is required to verify my full name and current location.

2. I understand there is a risk of being overhead by persons near me. I am responsible to use a location that is private and free from distractions.

3. I understand that I may expect the anticipated benefits from the use of telehealth in my care, but that no results can be guaranteed or assured.

4. I understand that audio and/or video recording of telehealth sessions is prohibited.

5. I understand that I have the right to withhold or withdraw my consent to use of telehealth at any time, without it affecting my right to future services.

6. I understand that if I am experiencing a medical or mental health emergency, that I will be directed to contact 911 for emergency medical care, and that my telehealth provider is not able to connect me directly to any local emergency services.

7. I have a right to confidentiality under the same laws that govern in person sessions. However, staff are mandated reporters for reporting child abuse and neglect, and elderly abuse and neglect to authorities. Additionally, staff must contact authorities if I am at risk of hurting or killing myself or someone else.

8. I understand there are risks associated with Telehealth, including, but not limited to the possibility despite reasonable efforts on the part of my telehealth provider, that: the transmission of my medical information could be disrupted or distorted by technical failures; the transmission of my medical information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons.