TELEHEALTH FORM

Please complete the SECURE on-line form below.

1. I hereby authorize Tift Area Psychiatric and Counseling Services to use the telehealth practice platform for telecommunication for evaluating, testing and diagnosing my medical condition.

2. I understand that technical difficulties may occur before or during the telehealth sessions and my appointment cannot be started or ended as intended.

3. I accept that the professionals can contact interactive sessions with video call.

4. I understand that my current insurance may not cover the additional fees of the telehealth practices and I may be responsible for any fee that my insurance company does not cover.

5. I agree that my medical records on telehealth can be kept for further evaluation, analysis and documentation, and in all of these, my information will be kept private.

6. I understand that HIPAA compliance and privacy for clients are being maintained but I cannot be guaranteed privacy on my end by Tift Area Psychiatric and Counseling. I am responsible for maintaining privacy of the appointment and session on my end.

7. Clients scheduled are expected to click the link sent to them no more than 5 minutes and no later than 15 minutes ensuring the session starts on time.


tiftareapacs.com

Tiftarea Psychiatric and Counseling Services, LLC. | Office Address: 223 East 2nd Street Suite B Tifton, Georgia 31794
Phone: 229-339-3721 | Fax: 229-472-9151 | Mailing Address: Post Office Box 1613 Tifton, Georgia 31793
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