This confidentiality agreement would normally be part of a broader agreement called the information form. In some circumstances, a therapist may have separate forms to address the various issues from which the informed consent form is collected. This can allow a better understanding of the customer in any area that could occur. In that case, I will provide the proposal for the confidentiality agreement. It is precisely this part that will address precisely these limits and nothing else. Feel free to copy this installation and use it for your own purposes when creating your own version of an informed consent document. The signed client (“customer”) authorizes and authorizes the client 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.