Consent for Tele-Health Services
Updated: January 07, 2025
Scope of services provided by the Providers hired by or working on behalf of Engine Tech LLC (DBA Skyler Health) can include psychological evaluation and other assessment and counseling and therapy services. Neither Skyler Health, nor any provider who provides services on Skyler Health’s behalf, can promise any specific results, including that your behavior or circumstance will change.
Please note that face-to-face sessions through video conferencing are highly preferable to phone sessions for treatment purposes. However, phone sessions are available under certain circumstances and when necessary and appropriate.
I consent to the following:
I wish to engage in a telehealth consultation with my Skyler Health health care provider.
I understand that the video conferencing technology that will be used to affect such a consultation will not be the same as a direct client/health care provider visit due to the fact that I will not be in the same room as my provider.
I understand that while a telehealth consultation has potential benefits, including easier access to care and the convenience of meeting from a location of my choosing, I understand that no such benefits or specific results can be guaranteed.
I understand there are potential risks to this technology, including interruptions, unauthorized access, and delays in medical evaluation and treatment arising from technical difficulties, technical difficulties and inability of my health care provider to provide appropriate medical treatment for my condition via electronic consultation. I understand that my healthcare provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.
I understand that my Skyler Health care provider may determine in his or her sole discretion that my condition is not suitable for treatment using the telephonic medical consultation, and that I may need to seek medical care and treatment from an alternative source.
I understand that in the event of an emergency, I should not contact Skyler Health but should immediately call “911” and/or the National Suicide Prevention Hotline, as applicable, and request emergency care assistance.
I understand that I may withhold or withdraw this consent at any time by providing Skyler Health with such notice. Otherwise, this consent will be considered renewed and ongoing upon each onsite visit or telemedicine consultation provided by Skyler Health and its affiliated professional entities and their health care providers.
Consent to Treatment Via Telehealth: I consent to participate in telemental health services. I understand that I have the right to refuse telemental health services and be informed of alternative services that may be available to me. If I request alternative services, I understand that Practice may not be able to provide those services, and that I may experience delays in service, the need to travel, or any other risks associated with not having services provided via telemental health, as well as risks associated with receiving telemental health services in an off-site location. I understand that telehealth may result in certain risks that are less likely to occur with in-person services, such as technology failure, need for specialized electronic security systems, and less visibility of non-verbal cues. Telehealth can also provide benefits not present with in-person services, such as creating greater flexibility for when and where services may be provided.
Assignment of Benefits / Financial Responsibility
I acknowledge the payment and insurance information set forth below and agree to pay for services rendered to me and/or facilitate the payment for services rendered to me by the providers affiliated with any of the behavioral health groups managed by Headway or Skyler Health (collectively referred to as Practice).
Payment of Fees: I agree to pay for charges for services as described in this agreement. I understand that:
Payment for sessions with providers affiliated with Practice is payable online through debit or credit card or ACH transfer, unless otherwise established
Payment for sessions is due after each session unless otherwise agreed upon and Practice will charge my card or bank account for my responsibility. Receipts may be provided at the time of the charge or monthly
I will be charged for sessions that I do not keep, unless I provide enough notice to the provider affiliated with the Practice (your treating provider will tell you how much notice is required to avoid being charged for sessions you do not keep)
I understand that I cannot submit bills for cancellations to my insurance company or managed care plan
Insurance and Managed Care Plans: Practice participates in a number of insurance and managed care plans. If Practice participates in my plan, I agree to pay all applicable deductibles, co-payments, co-insurances and any other form of cost-sharing. If my insurance benefits run out, Practice will inform me of the ending date, and I will then be responsible for all charges dating from the end of insurance coverage. If my insurance plan denies the visit despite Practice following necessary procedures, I understand I may be responsible to pay in full for the service.
The services or supplies you are requesting may be non-covered services(s) by your health plan. If payment is not received from your insurance carrier within 60 days, you will be expected to pay the balance in full.
Assignment of Insurance Fees; Release of confidentiality for authorization of benefits and for clinical care:I agree to allow my insurance plan or managed care plan to pay Practice directly, instead of paying me. In the event that my plan pays me directly, I will promptly turn the payment over to Practice unless I have already paid the charges myself. I authorize Practice to provide my insurance plan or managed care plan any information reasonably required to obtain insurance benefits and authorization for services. I authorize Practice to obtain at any time during my treatment here, any and all relevant clinical information from clinicians and facilities that have treated me and to furnish relevant clinical information to providers who will continue to treat me. I will indicate in writing any exceptions to this.
I authorize Skyler Health personnel to use Headway patient portal on my behalf to submit personal information, schedule sessions, submit session and payment details as necessary to schedule sessions in the Headway portal to get paid for the sessions.
Your digital acceptance and consent of this form acknowledges that you agree to bear full financial responsibility for all services requested by you.
Consent for Use of Generative AI Tools and Note Taking Digital Applications
I hereby give my informed consent to Skyler Health and it’s providers for the use of Generative AI (GenAI) tools and Digital Note Taking Applications (Note DTx). I understand and agree to the following:
1. Purpose: During your session with our therapists, we may use GenAI and Note DTx applications to assist us with transcribing and summarization of the audio video session(s) as well as documentation review, diagnostics support and other clinical tasks and recommendations if appropriate. These tools create efficiencies that enable us to provide more cost effective and clinically appropriate services. However, they are not a substitute for provider judgment and experience. If we use GenAI and Note DTx applications, we will independently review GenAI and Note DTx assisted work products for accuracy, completeness and compliance with applicable laws, rules and regulations. In addition, if we anticipate that the use of GenAI and Note DTx in the performance of a task will raise significant risks or influence a significant decision in your matter, we will consult with you before using GenAI and Note DTx production for that task. If you do not want us to use GenAI and Note DTx applications in our representation of you, you must notify us immediately.
2. Confidentiality and Privacy: All data generated by GenAI and Note DTx applications will be handled in accordance with HIPAA and applicable state privacy laws. Only authorized personnel will have access to the production.
3. Third-Party Involvement: The GenAI and DTx applications are provided by a third-party providers. I understand that while reasonable measures will be taken to ensure data privacy, Skyler Health cannot control all aspects of security on third-party platforms.
4. Data Security and Storage: The GenAI and NoteDTx productions will be stored securely as part of my health record within Skyler Healths systems, following standard data protection practices.
5. Right to Withdraw Consent: I have the right to withdraw this consent at any time by notifying Skyler Health in writing at care@skylerhealth.com. Withdrawal of consent will not affect any prior transcriptions but will prevent future transcriptions of my sessions using GenAI and NoteDTx applications.