SCCT -English

Date: * +

Please tell us what your relationship is to who is being referred: *

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Home or Cell Phone Number *

Work Number

Email Address *

Date of Birth *

Age *

Gender *

Social Security Number

Pharmacy Name. If none, write "none" *

Pharmacy Address and Phone Number. If none, write "none" *

Briefly description of the reason you wish services *

Who is your Primary Care Physician. If none, write "none". *

List any medications including over the couneter medications you are taking. If none , then write "None" in box. *

I have read Solutions Counseling Center of Tampa's Client Agreement, Informed Consent, Office Policies, and General Information carefully. I understand them and agree to comply with them. I have read, understood and received a copy of the HIPPA regulations. *

Yes

I have read the below Solutions Counseling Center of Tampa's Client TeleMedicine Informed Consent information carefully. I give my consent to receive services via TeleMedicine.

Yes

I understand that Solutions Counseling Center of Tampa wishes me to engage in a telemedicine consultation.
Solutions Counseling Center of Tampa has explained to me how the video conferencing technology will be used to affect such a consultation will not be the same as a physician/therapy visit due to the fact that I will not be in the same room as my therapist.
I understand there are potential risks to this technology, including interruptions, unauthorized access and technical difficulties. I understand that my physician/therapist or I can discontinue the telemedicine consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.
I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Others may also be present during the consultation other than my physician/therapist order to operate the video equipment. The abovementioned people will all maintain confidentiality of the information obtained. I further understand that I will be informed of their presence in the session and thus will have the right to ask other personnel to leave the telemedicine room or terminate the session at any time.
I have had the alternatives to a telemedicine explained to me, and in choosing to participate in a telemedicine consultation.
I understand that billing will occur from both my physician/therapist and as a facility fee from the site from which I am presented.
I have had a direct conversation with my physician/therapist during which I had the opportunity to ask questions in regard to this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.

By giving my consent, I certify:

That I have read or had this form read and/or had this form explained to me
That I fully understand its contents including the risks and benefits of the procedure(s).
That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.

Please sign here: *

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