Telehealth Consent Form – Nutrition

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Telehealth Acknowledgment + Waiver - Nutrition

The Dempsey Center for Quality Cancer Care is committed to improving the health and wellbeing of our clients. Telehealth Services is a means of providing nutrition consultation to clients, when a face-to-face session is for any reason not feasible or not recommended for health or safety reasons. The COVID-19 virus and government recommendations for “social distancing” support the use of Telehealth as an alternative to in-person nutrition consultation sessions.

Definition:
Telehealth Services means the use of information technology by a health care provider, such as a dietitian, to deliver clinical services at a distance for the purpose of diagnosis, disease monitoring, or treatment. Telehealth Services require an audio component and a video, unless a video device is not available. Telehealth Services do not include the use of social media, texting or email.

What to Expect:
You will have a scheduled time to meet with your dietitian, and you will receive instructions for how to access the on-line session. You will need to use your own device, such as a smartphone, tablet or computer to connect with your dietitian. The nutrition consultation session will proceed similarly to a face to face session, whether group or individual.

Terms of Use, Risks, and Benefits:
(1) Telehealth Services are voluntary. You have the right to decline to receive Telehealth Services without affecting your eligibility for or access to future sessions or resources.

(2) The same risks that apply with respect to nutrition consultation in general also apply to Telehealth Services.

(3) You have the right to confidentiality of your protected health information. Dempsey Centers shall strive to
  1. prevent the unauthorized disclosure of an identifiable image of you and
  2. prevent the disclosure of any other confidential information obtained during a Telehealth session. HOWEVER, the unique nature of telehealth sessions presents risk to you of certain disclosures:,

    • there is risk that the communication will not be as easy or natural;
    • despite reasonable efforts on the part of your dietitian, the transmission of healthcare information could be disrupted or distorted by technical failures or by unauthorized persons;
    • your location may not afford you the same privacy as being in the Dempsey Centers office. We recommend that you find a private, quiet space where you will not be interrupted and where you can speak without being overheard.
(4) You have the right to access the same information generated in a record of the Telehealth Services, as you would have the right to a record generated from the same health services provided face-to-face in the same room.

(5) You have the right to be informed of the parties present at either the Dempsey Centers’ location or the location where you are engaging in the Telehealth Service. You have the right to exclude others from participating in your individual telehealth session.

(6) You have the right to object to the videotaping or other recording of Telehealth Services. Any videotaping or record would only occur with notice, and your advance written consent.

The most significant benefit to Telehealth Services is that you can receive services without risk of exposure to the COVID-19 virus or other communicable diseases, since you are not in physical proximity with others.

Emergency Contact:
Please provide the name and phone and e-mail address for a local, Emergency Contact Person. This is a prerequisite to participation in a telehealth session. If an urgent or emergent situation arises involving your health, safety or well-being your provider may:
  • alert your emergency contact person;
  • end or reschedule the Telehealth Services for another day/time;
  • contact 911 if it is determined that emergency intervention is required;
By signing this form and providing an Emergency contact, you are confirming that your Dempsey Center provider may contact this person.
Emergency Contact(Required)

Consent to Receive Telehealth Services

By signing below, I am confirming that I have reviewed the above educational information regarding Telehealth Services, that I have had a chance to ask questions of my Telehealth Services Provider and have had all of my questions answered to my satisfaction.

I am confirming that I consent to the receipt of Telehealth Services.
Name(Required)
MM slash DD slash YYYY
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Parent or Authorized Representative Name (if applicable):
I understand that my typed name above will carry the same effect as my written signature(Required)