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click here For a copy of your mental health records sent to the provider of your choice for those of you who want a change of psychiatrist. 


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​PLEASE READ CAREFULLY "TELEPSYCHIATRY" BELOW.

    TELEPSYCHIATRY (Audio-only telephone and/or live FaceTime-iphone video visits)
    Introduction
    Tele-psychiatry 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.

    Potential Benefits 
    .  Increased accessibility to psychiatric care.
    .  Patient convenience.

    Potential Risks 
    As with any medical procedure, there may be potential risks associated with the use of Tele-psychiatry. These risks include, but may not be limited to:
    • Information transmitted may not be sufficient (e.g., poor resolution of video) to allow for         appropriate decision-making by your provider.
    • Your 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.
    • Your provider may not be able to perform certain physical exam parameters, or check vital          signs (weight, blood pressure) as in a face-to-face session.     . Delays in medical evaluation and treatment may occur due to deficiencies or failures of the    equipment.
    • Security protocols can fail, causing a breach of privacy of confidential health information.        There is no absolute guarantee of total protection against hacking or tapping into the     telepsychiatry session by outsiders.
    • A  lack of access to all the information that might be available in a face to face in-office visit, but        not in a telepsychiatry session, may result in errors in judgment.

    Alternatives to the Use of Telepsychiatry 
    . Traditional face-to-face sessions in a provider’s office of my choice. 
    . I  understand that I can change my current psychiatrist Dr. Angeles, at any time particulary if      I prefer face-to-face in-office sessions.  


    ​Patient’s Rights 
    • I  understand that the laws that protect the privacy and confidentiality of 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; when I       expressed suicidal threats; and where I make my mental or emotional state an issue in a legal   proceeding.
    .         I  understand that there are risks and consequences from telepsychiatry, including, but not limited to, the possibility, despite reasonable efforts on the part of Dr. Angeles, that the transmission of my medical and mental health information could be disrupted or distorted by technical failures; the transmission of my medical and mental health information could be interrupted by unauthorized persons; and/or could be accessed by unauthorized persons.
     Important Notice: 
    The Office for Civil Rights (OCR) at the Department of Health and Human Services issued a relaxation of HIPAA Rules and Regulations such that “covered health care providers may use popular applications that allow for video chats, including Apple FaceTime, …related to the good faith provision of telehealth during this COVID-19 nationwide public health pandemic.”(HHS.gov 03-30-2020) .
    . 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 telepsychiatry based services and care may not be as complete as face-to- face services. I also understand that if Dr. Angeles 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 who can provide such services in my area. I understand that there are  potential risks and benefits associated with any form of psychiatry, and that despite my efforts   and the efforts of DR. Angeles,  my condition may not improve,  and in some cases may even   get worse.
    . I  have the right to withhold or withdraw my consent to the use of telepsychiatry during the      course of my care at any time.
    • I  have the right to inspect all medical information that includes the Tele-psychiatry visit. I may   obtain copies of this medical record information for a reasonable fee.
    • I  understand that Dr. Angeles has the right to withhold or withdraw consent for the use of Telepsychiatry during the course of my care at any time.
    • I  understand that the all rules and regulations that apply to the provision of healthcare services      in the State of California  also apply to Tele-psychiatry.

    Patient’s Responsibilities
    .  I  understand that Dr. Angeles is located in  and licensed by the State of California. Dr. Angeles may not be able to prescribe medications for me and/or may not be able to assist me in an emergency situation when I am located in any other state or country.
    If I require medication,  I may contact Dr. Angeles.  If I require emergency care, I will call 911 or proceed to the nearest hospital emergency room for help.  If I am having suicidal thoughts or making plans to harm myself, I will call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255) for free 24-hour hotline support.
    .  I  submit to the exclusive jurisdiction of the California state superior courts and agree that any claim, lawsuit, or other legal proceeding arising out of or relating to the telepsychiatry services provided by Dr. Angeles and her staff will be brought solely and exclusively in California state superior courts.  I also agree that the interpretation of this consent will be exclusively governed by and construed in accordance with the laws of California.
    .  I  understand that Dr. Angeles believes that telepsychiatry services are appropriate for     my medical condition and that I would benefit from its use despite its risks and limitations. While I may expect anticipated benefits from the use of telemedicine, no specific results can be guaranteed or assured.
    . I  understand that I must be in a quiet place to avoid potential distractions during Tele-psyhiatry sessions with Dr. Angeles.
    (Use of headphones or earbuds with a microphone are strongly recommended.)
    .  I  understand that I will not record nor take any pictures of any Tele-psychiatry sessions with Dr. Angeles without mutual consent from both of us.
    .  I  understand that Dr. Angeles will not record nor take any pictures of any of our Tele-psychiatry sessions without mutual consent from both of us.
    .          I  understand that Dr. Angeles will be taking contemporaneous notes during Tele-psychiatry sessions which will be included in my paper medical records.
    • I  will inform Dr. Angeles if any other person can hear or see any part of our session before  the session begins. Dr. Angeles will inform me if any other person can hear or see any part of our session before the session begins.
    .  I  understand that while Dr. Angeles and her assistant staff take reasonable steps to maintain the security and confidentiality of my patient-health-information (PHI), however Dr. Angeles and her assistant staff are not liable for improper disclosure of my confidential information caused by me or by third-party applications.
    • I  understand that I, not Dr. Angeles, 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 California to be eligible for Tele-psychiatry services from
    ​ Dr. Angeles.
    . I  will be required to verify my identity.

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    PATIENT CONSENT TO THE USE OF TELEPSYCHIATRY
     I HAVE READ AND FULLY UNDERSTAND THE INFORMATION PROVIDED ABOVE REGARDING TELE-PSYCHIATRY. BY CLICKING THE SUBMIT BUTTON BELOW,  I  GIVE MY INFORMED CONSENT FOR THE USE OF TELE-PSYCHIATRY IN MY HEALTH CARE AND AUTHORIZE THELMA ANGELES M.D. TO USE TELE-PSYCHIATRY IN THE COURSE OF MY DIAGNOSIS AND TREATMENT.
    Please make check (your payment) payable to: Thelma Angeles M.D.
    and mail to: Thelma Angeles M.D.                                                     
                          PO BOX 7272
                          Long Beach CA 90807