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Telehealth Services Agreement

Program Description

Telehealth Services can be offered through any BIS program and are intended to enhance existing program services.


In order to be considered for participation in the BIS Telehealth Services, a client must have a desire to use the technology & meet the following criteria

  1. Currently is a BIS client (participating in any program or group)
  2. Sign the “Telehealh Informed Consent” in the Client Handbook
  3. Have prior experience using a laptop or tablet
  4. Currently have access to internet or Wi-Fi (those using loaner iPad)
  5. Have access to a tablet or laptop

Service Delivery

For Telehealth Services, BIS staff will use a secure, encrypted wireless network currently provided by Zoom. Zoom is a HIPAA compliant remote conferencing service that enables individuals and group members to meet remotely utilizing a laptop or other device for audio/video therapy.

BIS staff will NOT record any telehealth session

  • At the beginning of each session, BIS staff member will clarify who is attending at both the original and remote sites.
  • Any material for the session will be provided to the client prior to the session
  • Clients will be screened prior to participation in services to ensure they are utilizing a safe and private, encrypted wireless network.
  • Clients are also responsible for the device they will use whether it is privately owned or borrowed from BIS.
  • If clients are provided a “loaner” device from a BIS staff, the Loaner Agreement will be signed.

Acknowledgement of Handbook- Telehealth Services
Telehealth Informed Consent

Clients who participate in remote individual and/or group services are responsible for ensuring that they are utilizing a safe and private, encrypted wireless network and a private space to ensure privacy on their end of the electronic transmission. This is to protect their own confidentiality and/or that of other group participants.

I understand that there are risks and consequences from distance services, including the possibility, despite reasonable efforts, that sessions may be interrupted by technical failures and that information could be accessed by unauthorized persons during the video conference. These risks should be offset by use of a HIPPA compliant service which is encrypted for video teleconference style health communications (Zoom). Staff will do their best to keep information confidential, but with partners or children in the home there is a chance that someone might walk in during a virtual meeting.

Additional risks may include privacy concerns that may be out of the control of the client or staff such as how other participants in a group manage privacy while participating from a remote location. I understand these risks and agree to take responsibility to ensure that my wireless network is encrypted and secure and agree not to utilize a public WIFI network that is not secure or meet in a public or shared space while participating in individual or group services. I agree to share my location during the remote session and my emergency contact information for use in the event of an emergency for which I am unable to contact anyone myself, and particularly if my staff and I are located in different 9-1-1 jurisdictions.

I have read and understand the information provided above. I have discussed it with BIS staff, and any questions have been answered to my satisfaction.

This consent is valid for one year from date signed and can be revoked at any time by the signer.