TELEHEALTH INFORMED CONSENT (Electronic Attestation)
Effective Date: 2/9/2026
Telehealth involves the delivery of health care services using electronic communication technologies when you and your provider are in different physical locations. This consent applies to non-prescribing behavioral health services provided by Birches Health via telehealth.
Nature of Telehealth Services
Telehealth may include one or more of the following modalities, as determined appropriate by your provider and permitted by law:
Live, interactive video sessions
Telephone-only sessions, when clinically appropriate and permitted
Secure messaging or patient portal communications
Review of information you provide, such as screening tools, questionnaires, or health history
Your provider will determine whether telehealth is clinically appropriate for your needs at each encounter.
Benefits of Telehealth
Potential benefits of telehealth include improved access to care, convenience, continuity of services, and the ability to receive care when in-person services may not be reasonably available.
Risks and Limitations
You understand that telehealth has limitations and potential risks, including but not limited to:
Technology failures, interruptions, or poor connection quality
Reduced ability to assess certain conditions compared to in-person care
Privacy risks if your device, internet connection, or physical environment is not secure
The possibility that telehealth may not be appropriate for all clinical situations
If telehealth is not clinically appropriate or technically feasible, your provider may recommend in-person services or referral to another provider.
Patient Location and Provider Licensure
You understand and agree that:
Telehealth services may only be provided while you are physically located in a state where your provider is licensed or otherwise authorized to practice.
You are responsible for accurately disclosing your current physical location (city and state) at the time of each telehealth visit.
If your location changes during a visit, you must inform your provider immediately.
Birches Health may be unable to provide services if you are located in a state where the provider is not authorized to practice.
Privacy and Confidentiality
Telehealth services are subject to the same federal and state privacy laws as in-person care, including HIPAA. Birches Health uses reasonable administrative, technical, and physical safeguards to protect your information. However, you understand that no electronic system can be guaranteed to be completely secure.
Emergencies and Crisis Situations
Telehealth services are not appropriate for emergencies.
If you are experiencing a medical or mental health emergency, you must call 911 or go to the nearest emergency room.
If your provider believes you are at imminent risk of harm to yourself or others, or if otherwise required or permitted by law, your provider or Birches Health may take appropriate protective actions, including contacting local emergency services or other appropriate resources based on your disclosed location.
Birches Health (Non-Emergency Contact): (833) 483-3838
Hours: Monday–Friday, 9:00 a.m. – 5:00 p.m. (excluding federal holidays)
Alternatives to Telehealth
You understand that alternatives to telehealth, including in-person services, may be available to you. You may request alternative services at any time, although availability may depend on provider licensure, location, and clinical appropriateness.
Right to Refuse or Withdraw Consent
You have the right to refuse telehealth services or to withdraw your consent at any time. Withdrawal of consent will not affect your right to future care; however, alternative care options may be limited based on geography, licensure, or clinical considerations.
Telehealth Informed Consent Electronic Attestation
By selecting “I Agree,” continuing with scheduling, or participating in telehealth services with Birches Health, you electronically attest that:
You have read and understand this Telehealth Informed Consent.
You have had the opportunity to ask questions and have received satisfactory answers.
You understand the nature, benefits, risks, and limitations of telehealth behavioral health services.
You understand the requirements regarding your physical location and provider licensure.
You understand that telehealth is not appropriate for emergencies.
You consent to receive behavioral health services via telehealth as described above.
Your electronic attestation constitutes your informed consent and is documented and maintained in your medical record in accordance with applicable federal and state laws.
I understand that the above methods of unencrypted communication will be used to communicate with me about Birches Health’s services, for my own convenience, and I accept all risks associated with them (including, without limitation, risks of improper exposure of my medical information). I have read the Terms of Service and Privacy Policy.