TARAL SHARMA, MD, PC

120 PELHAM LN

Phone: (864) 844 – 9432

Fax: (864) 844-9430

TELEPSYCHIATRY PATIENT CONSENT FORM

In order to receive telepsychiatry services from Taral Sharma MD PC, you must be a South Carolina State Resident.

Telepsychiatry is the delivery of psychiatric services using interactive audio and visual electronic systems between a provider and a patient that are not in the same physical location. These services may also include electronic prescribing, appointment scheduling, communication via email or electronic chat, electronic scheduling, and distribution of patient education materials.

The potential benefits of telepsychiatry are:

The potential risks of telepsychiatry include, but are not limited to:

Alternatives to the use of telepsychiatry:

I understand that I have the following rights with respect to telepsychiatry:

  1. I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment nor risking the loss or withdrawal of any program benefits to which I would otherwise be entitled.
  2. The laws that protect the confidentiality of my medical information also apply to telepsychiatry. As such, I understand that the information disclosed by me during the course of my treatment is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding.
    I also understand that the dissemination of any personally identifiable images or information from the telepsychiatry interaction to researchers or other entities shall not occur without my written consent.
  3. I understand that there are risks and consequences from telepsychiatry, including, but not limited to, the possibility, despite reasonable efforts on the part of my psychiatrist/therapist, that: the transmission of my medical information could be disrupted or distorted by technical failures; the transmission of my medical information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons.
    In addition, I understand that telepsychiatry based services and care may not be as complete as faceto- face services. I also understand that if my psychiatrist/therapist believes I would be better served by another form of psychiatric services (e.g. face-to- face services) I will be referred to a psychiatrist/therapist who can provide such services in my area. Finally, I understand that there are potential risks and benefits associated with any form of psychiatry, and that despite my efforts and the efforts of my psychiatrist/therapist, my condition may not be improve, and in some cases may even get worse.
  4. I understand that I may benefit from telepsychiatry, but that results cannot be guaranteed or assured.
  5. I understand that I have a right to access my medical information and copies of medical records in accordance with South Carolina Law.

Patient’s Responsibilities
I will not record any telepsychiatry sessions without written consent from my provider. I understand that my provider will not record any of our telepsychiatry sessions without my written consent.
I will inform my provider if any other person can hear or see any part of our session before the session begins. The provider will inform me if any other person can hear or see any part of our session before the session begins.
I understand that I, not my provider, am responsible for the configuration of any electronic equipment used on my computer that is used for telepsychiatry. I understand that it is my responsibility to ensure the proper functioning of all electronic equipment before my session begins. I understand that I must be a resident of the State of South Carolina to be eligible for telepsychiatry services from Taral Sharma MD PC.
I understand that my psychiatrist/therapist determines whether or not the condition being diagnosed and/or treated is appropriate for a telepsychiatry encounter.
I understand that if the telepsychiatry session does not achieve everything that is needed, then I will be given a choice about what to do next. This could include a follow up face-to- face visit, or a second telepsychiatry visit.
I can change my mind and stop using telepsychiatry at any time, including in the middle of a video visit. This will not make any difference to my right to ask for and receive health care.


Patient Consent To The Use of Telepsychiatry:
I hereby consent to engaging in telepsychiatry with Taral Sharma MD PC as part of my psychiatric evaluation and treatment. I understand that "telepsychiatry" includes the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, or data communications. I have read and understand the information provided above regarding telepsychiatry.

Name of Patient:
Signature of Patient or Representative:
Signature of Witness:
Date: