TELEPSYCHIATRY PATIENT CONSENT FORM
In order to receive telepsychiatry services from Taral Sharma MD PC, you must be a South Carolina
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:
Reduced wait time to receive psychiatric care.
Avoiding the need to travel to a psychiatrist/therapist.
The potential risks of telepsychiatry include, but are not limited to:
A telepsychiatry session will not be exactly the same, and may not be as complete as a faceto-face service.
There could be some technical problems (video quality, internet connection) that may affect
the telepsychiatry session and affect the decision making capability of the provider.
The provider may not be able to provide medical treatment using interactive electronic
equipment nor provide for or arrange for emergency care that you may require.
A lack of access to all the information that might be available in a face to face visit, but not in
a telepsychiatry session, may result in errors in judgment.
Delays in medical evaluation and treatment may occur due to deficiencies or failures of the
Taral Sharma MD PC utilizes software that meets the recommended standards to protect the
privacy and security of the telepsychiatry sessions. However, the service cannot guarantee
total protection against hacking or tapping into the telepsychiatry session by outsiders. This
risk is small, but it does exist.
Alternatives to the use of telepsychiatry:
Traditional face-to-face sessions.
I understand that I have the following rights with respect to telepsychiatry:
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.
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.
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.
I understand that I may benefit from telepsychiatry, but that results cannot be guaranteed or
I understand that I have a right to access my medical information and copies of medical records in
accordance with South Carolina Law.
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
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