Peru State College Telehealth Informed Consent

Telehealth is healthcare provided by any means other than a face-to-face visit. In telehealth services,
mental health information is used for diagnosis, consultation, treatment, therapy, and follow-up. Health
information is exchanged interactively from one site to another through electronic communications.
Telephone consultation, videoconferencing, transmission of still images, e-health technologies, patient
portals, and remote patient monitoring are all considered telehealth services.
The purpose of this form is to obtain your consent for a telehealth visit with one of our Licensed Student
Counselors at Peru State College.

I am a resident of the State of Nebraska
I understand that telehealth involves the communication of my mental health information in an
electronic or technology-assisted format.
I understand that I may opt out of the telehealth visit at any time. This will not change my ability
to receive future care at this office.
I understand that telehealth services can only be provided to patients, including myself, who are
residing in the state of Nebraska at the time of this service.
I understand that the telehealth services through Peru State College’s Counseling Center are free
as they are when seeking on campus services.
I understand that all electronic medical communications carry some level of risk. While the
likelihood of risks associated with the use of telehealth in a secure environment is reduced, the risks are nonetheless real and important to understand. These risks include but are not limited to:
• It is easier for electronic communication to be forwarded, intercepted, or even changed without my knowledge
and despite taking reasonable measures.
• Electronic systems that are accessed by employers, friends, or others are not secure and should be avoided. It is important for me to use a secure network.
• Despite reasonable efforts on the part of my healthcare provider, the transmission of medical information could be disrupted or distorted by technical failures.
I agree that information exchanged during my telehealth visit will be maintained by the
Counseling Center at Peru State College.
I understand that I must take reasonable steps to protect myself from unauthorized use of my
electronic communications by others.
The healthcare provider is not responsible for breaches of confidentiality caused by an
independent third party or by me.
I agree that I have verified to my healthcare provider my identity and current location in
connection with the telehealth services. I acknowledge that failure to comply with these procedures
may terminate the telehealth visit.
To the extent permitted by law, I agree to waive and release my healthcare provider and his or
her institution or practice from any claims I may have about the telehealth visit.
I understand that electronic communication should never be used for emergency
communications or urgent requests. Emergency communications should be made to the existing
emergency 911 services in my community.
I certify that I have read and understand this agreement and that all blanks were filled in prior to my
signature with the opportunity to have questions answered to my satisfaction.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date Date / MM / DD YYYY
I certify that I have explained the nature of this agreement to the client seeking mental health services through Peru State College Counseling Center. I have answered all questions fully, and I believe that the student fully understands what I have explained.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date Date / MM / DD YYYY