SECTION 1: PARTICIPANT TELEHEALTH AGREEMENT LETTER

 

As you are aware, the Novel Coronavirus (COVID-19) has impacted the daily lives of all Californians. The latest direction from the Department of Health Care Services (DHCS) allows for the provision of temporary Remote Client Services also known as Telehealth.

In an effort to engage and support our clients, Bridges Professional Treatment Services will begin offering Remote Outpatient Treatment on Monday, April 13, 2020.

Remote Client Services will enable you to participate in Treatment with a certified counselor via a virtual meeting platform (“ZOOM”) temporarily during the COVID-19 crisis.

To take advantage of this unique opportunity you must be willing and able to agree to the following Remote Client Services requirements:

  • Have access to the necessary technology (smartphone, tablet, computer)
  • Download “ZOOM” (FREE Software download for computer or app download)
  • (You must also read, agree to and sign Zoom’s Privacy Policy)
  • Understand that to receive credit you must:
    • Attend the session in a private room, free of distractions.
    • Stay for the entire session.
    • Not be under the influence of alcohol or other drugs during the session.
    • Protect the confidentiality of others.

By signing here, I certify that I have read, understand and agree to the above-stated terms.

Date:

Your Signature:

 

 

SECTION 2: PRIVACY POLICY FOR REMOTE CLIENT SERVICES

 

Bridges Professional Treatment Services will provide Remote Client Services (Telehealth) utilizing the “ZOOM” Virtual Meeting Platform. Some personal information such as your name, email address, and computer IP address will be shared with Zoom. Additionally, some meetings may be recorded and uploaded to a cloud for documentation of session completion.

To participate in Zoom meetings, you must read and agree to Zoom’s Privacy Policy.

Bridges Professional Treatment Services will continue to maintain confidentiality as stated in our Confidentiality Policy. Clients will also be held to the Confidentiality Agreement signed upon enrollment. 

Remote Client Services Release

 

I ________________________, agree to participate in temporary Remote Client Services (Telehealth) at Bridges Professional Treatment Services. I understand that specific technology is required to participate, and I certify that I have access to the required technology. Additionally, I have read and understood the Zoom privacy policy. I understand that Remote Client Services are being offered on a temporary basis due to the Coronavirus (COVID-19) pandemic, and that once the threat is eliminated, client services will return to the program site.

I understand that the payment policy I signed at intake remains valid during this time allowing for billing of services if applicable and/or requirement of payment for services if applicable. Bridges Professional Treatment Services will provide me with a Financial Assessment via telehealth should I request.

By signing here, I certify that I have read and agree to Bridges Professional Treatment Services and Zoom’s Privacy Policy.

 

Date:

Your Signature:

SECTION 3: ACCOUNT INFORMATION FOR TELEHEALTH LINKS

 

Fill in the following required information: