Verbal Consent



Note: Please read information about your upcoming telemedicine / telehealth / tele-psychiatry visit. You will be asked by your provider if you agree with this document and understand it. You can ask your provider any questions you may have.

  1. I authorize and voluntarily consent to the participation and treatment of myself in a Telemedicine Consultation and/or treatment with ACESO Behavioral Health (“ACESO”).
  2. I understand that as a participating patient, my physician and I will communicate by audio/video conferencing with physicians, mental health providers, and health care professionals at ACESO. I understand that medicine is not an exact science and there are no guarantees that can be made regarding outcomes and results of these examinations and treatments.
  3. It has been explained to me how the audio/video conferencing technology will be used to conduct a visit. I understand that this visit will not be the same as an in-person visit due to the fact that I will not be in the same room as the healthcare provider at the distant site. I also understand that I have the option to see a provider in person, if I chose.
  4. I further understand that there are potential risks to telemedicine, including but not limited to, interruptions, unauthorized access, and technical difficulties. I understand that either the healthcare provider or I can discontinue my child’s telemedicine health visit if it is felt that the videoconferencing connections are not adequate for the situation.
  5. I understand it may be necessary and useful for others to be present during the visit other than my healthcare team and provider in order to operate the a/v equipment. These individuals are bound to maintain confidentiality of all information obtained. 
  6. During my telemedicine visit, I understand that the responsibility of the telemedicine healthcare provider concludes upon the termination of the a/v conference connection and ACESO is not responsible for the actions of the distant site.
  7. By signing this consent, I authorize my physician to release any relevant medical information, pertaining to my medical condition and medical care to ACESO, its physicians, mental health providers, and healthcare professionals. I also authorize ACESO, or its providers, to release any and all information to my insurance company or any other agent that may be responsible for paying my medical bills. 
  8. I understand that I have the right to withdraw my consent at any time. If at any time I am not satisfied with the services rendered. 
  9. I have read (or have had read to me) this document carefully, and hereby consent to participate in the Telemedicine consultation/services under the terms described above.