UCS Telehealth Consent

agree to participate in Telehealth services with UCS Healthcare. Telehealth involves the use of electronic communications to enable UCS Healthcare providers to connect with individuals using interactive video and audio communications. I understand that this might include texting, phone calls, assessment, group or individual sessions by camera and other online platforms. I also understand that my particular issues may not be appropriate for telehealth sessions and if this is determined during a session that I will be notified immediately.


1.    I understand there is a lack of "personal" face-to-face interactions.

2.    I understand there is a lack of visual and audio cues on the phone, email or other telehealth processes.

3.    I understand that telephone/online/camera sessions is not a substitute for medication under the care of a psychiatrist or doctor.

4.   I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment.

5.    I understand that telehealth sessions may not be appropriate if you are experiencing a crisis or having suicidal or homicidal thoughts.

If a life-threatening crisis should occur, you agree to contact a crisis hotline, call 911, or go to a hospital emergency room.


The laws that protect the confidentiality of my personal information also apply to telehealth. As such, I understand that the information disclosed by me during the course of my sessions is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to, reporting child, elder, and dependent adult abuse; expressed threats of violence toward an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding. I also understand that the dissemination of any personally identifiable images or information from the telehealth interaction to other entities shall not occur without my written consent.

I understand that others may also be present during the consultation other than my provider in order to operate the video equipment. The above-mentioned people will all maintain confidentiality of the information obtained. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history that are personally sensitive to me, (2) ask non-clinical personnel to leave the telehealth room, and/or (3) terminate the consultation at any time.

I understand that there are risks and consequences from telehealth, including, but not limited to, the possibility, despite reasonable efforts on the part of the provider, that: the transmission of my personal information could be disrupted or distorted by technical failures, the transmission of my personal information could be interrupted by unauthorized persons, and/or the electronic storage of my personal information could be unintentionally lost or accessed by unauthorized persons. UCS Healthcare utilizes secure, encrypted audio/video transmission software to deliver telehealth.

I understand that my express consent is required to forward my personally identifiable information to a third party.

I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment.


Therapeutic email exchanges are delivered via secure email servers but absolute cyber protection cannot be guaranteed. If we are having sessions through camera we ensure confidentiality within the office, but the internet link may not be fully confidential. If you choose to email us from your personal email account, please limit the contents to basic issues such as cancellation or change in contact information. Your provider will not respond to personal and clinical concerns via regular email. If you call your provider, please be aware that unless you are both on landline phones, the conversation is not confidential. Likewise, text messages are not confidential. We make every effort to keep all information confidential. You understand that you need to be in a confidential area, with no one near you to see or hear in order to protect confidentially of yourself and other members of a group. Likewise, if we are working online together, determine who has access to your computer and electronic information from your location. This would include family members, co-workers, supervisors and friends. You are encouraged to only communicate through a computer that you know is safe, i.e. wherein confidentiality can be ensured. Be sure to fully exit all telehealth sessions and emails. If we are unable to connect or are disconnected during a session due to a technological breakdown, please try to reconnect within 10 minutes. If reconnection is not possible, email your counselor/therapist/provider to schedule a new session time.


UCS Healthcare will bill insurance for telehealth services when these services have been determined to be covered by an individual's insurance plan. In the event that insurance does not cover telehealth, the individual will be responsible for the bill. We will provide you with a statement of service to submit to your insurance company if you wish.

I have read this document carefully and understand the risks and benefits related to the use of telehealth services and have had my questions regarding the procedure explained. I hereby give my informed consent to participate in the use of telehealth services for treatment under the terms described herein.


I understand that my health records are protected under state( Iowa Code Chapter 228) , federal regulations (42 CFR, Part 2) and the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 C.F.R. Pts. 160 & 164 and cannot be disclosed without my written consent unless otherwise provided for in the regulations.   I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it, and that in any event this consent EXPIRES 365 DAYS AFTER MY DISCHARGE.  I understand that generally UCS Healthcare may not condition my treatment on whether I sign a consent form, but that in certain limited circumstances I may be denied treatment if I do not sign a consent form. I may review information released or ask questions by contacting the Compliance Officer at UCS Healthcare.

By my signature below, I hereby state that I have read, understood, and agree to the terms of this document.

If you are in crisis or suicidal, telehealth is not an effective mode of treatment for you. Please list an emergency contact that can be contacted in the event that you experience a crisis and we need to contact someone to insure your physical safety. Signature on this form indicates that this individual may be contacted.

By dating and filling in your name below, you are giving your electronic signature.