Sample Confidentiality Agreement For Group Therapy

If you decide to participate in a group on telehealth, you agree as follows: The client also agrees to protect the confidentiality of other members of the participating group personally or by telehealth: Unless you tell us more, this group telehealth authorization will also allow us to see you in tele-health for your individual sessions. Ethos Behavioral Health Group, LLC`s and their affiliates (“Ethos”) offer group therapy clients, in appropriate circumstances, the opportunity to participate in their group by telehealth. This option is only available if all participants in the group accept the permission and approval below. In order to protect the confidentiality of all members of the group, the client agrees: the signed client (“customer”) gives the customer permission and authorization to participate in the telehealth program of the Ethos Behavioral Health Group, LLC and its affiliates (“Ethos”). While Ethos` telehealth options, including Zoom, Facetime and Cisco Web, are optimistic about data protection, Ethos may not have formal agreements with business partners with these services (and these agreements are not available with Facetime), which may lead to technical data protection problems. The customer accepts that these third-party services serve as a channel for the client`s protected health information and may have access to that information. The client also understands that other people may see or ignore the client`s protected health information if the client is not in a private location while accessing the telehealth. The customer accepts and authorizes Ethos to transmit the customer`s protected health information to its telesursant providers or to all persons present when the customer accesses Ethos` telehealth service, as long as it is necessary for the use of Ethos` telehealth services for the purpose of treating the customer. The client also undertakes to waive all applicable federal and state data protection provisions, including, but not limited to, HIPPA protection and protection in accordance with 42 CFR, Part 2, as long as necessary to participate in ethos telehealth options described above. This authorization is maintained until the customer has revoked it. The customer can revoke this authorization at any time by contacting Ethos` compliance officer at tlankau@ethosbhg.com or 832-457-5046. The terms of the customer`s service with ethos are not affected if the customer decides not to sign this consent and authorization. Limited hippa and 42 CFR Part 2 TelehealthAppreation and authorization for group therapy .

[contact-form-7 id”43997″ title”Group Consent”] .

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