CONSENT FOR TELEHEALTH CONSULTATION WITH LTAI AI ADVISOR

I understand that I am being offered a telehealth consultation through the LTAI AI Advisor platform, a service designed to provide general advisement and support for managing mental health challenges and addiction issues.

Nature of the Telehealth Consultation:

I understand that the telehealth consultation provided by the LTAI AI Advisor will utilize video conferencing technology. This consultation differs from a traditional, in-person visit, as I will not be physically present in the same room as the AI advisor.

Benefits of Telehealth Consultation:

I acknowledge that telehealth consultation offers potential benefits, including:

Easier Access to Care: The ability to receive advisement from the convenience of any given or chosen location.

Increased Flexibility: A wider range of consultation times and reduced need for travel.

Risks of Telehealth Consultation:

I am aware that telehealth consultations may present certain risks, including:

Technical Issues: Interruptions, unauthorized access, or technical difficulties could potentially occur during the consultation.

Quality of Connection: Either I or the LTAI AI Advisor may choose to discontinue the consultation if the video conferencing connection is deemed inadequate for the consultation.

Discussion with Provider:

I have had a direct conversation with the LTAI AI Advisor, during which I was given the opportunity to ask questions regarding the telehealth process. My questions have been answered, and the risks, benefits, and practical alternatives to telehealth have been explained to me in a language I understand.

Consent to Use the LTAI Telehealth Service:

The LTAI AI Advisor platform is the technology service that will be used to conduct telehealth video conferencing consultations. By agreeing to this document, I acknowledge and understand the following:

Non-Emergency Service: The LTAI AI Advisor platform is not an emergency service. In the event of an emergency, I will use a phone to call 911 or contact local emergency services.

Limitations of Service: The LTAI AI Advisor platform facilitates videoconferencing for advisement purposes only. It does not provide any medical or healthcare services, nor does it offer medical advice or care, including emergency or urgent medical services.

No Assumption of Provider’s Technical Knowledge: I do not assume that the LTAI AI Advisor or any other provider has access to all technical information within the telehealth service, nor do I assume that such information is current, accurate, or up-to-date. LTAI will provide the best advice based on trauma-informed and evidenced-based best practices information.

Confidentiality: To maintain confidentiality, I agree not to share my telehealth appointment link with anyone unauthorized to attend the consultation.

Certification of Understanding:

By clicking on the checkbox below or signing this form, I certify that:

I have read or had this form read to me, and/or had this form explained to me.
I fully understand its contents, including the risks and benefits of the telehealth consultation.
I have been given ample opportunity to ask questions, and all questions have been answered to my satisfaction.

Agreement:

By clicking the Accept button below, I agree that I have read, understood, and agree to the items contained on this page.