Portal and Tele psych Agreement
Charm Portal
Shafa Psychiatry Center uses a HIPAA compliant email and patient portal system managed by Charm.com. If authorized by your signature below, our practice will send appointment confirmations, appointment reminders, and invoices via email through the Charm portal, and will send and respond to email messages only through this portal. These communications will contain protected health information and you must be aware that although messages sent via Charm are secure, they are potentially able to be obtained by an outside source if Charm is hacked. If you do NOT want any information sent via the Charm portal, including receipts for sessions for submission to insurance, please select the relevant option below. If this is a concern for you, all clinical information should be directed only to Dr. Khosravi secure voicemail and all invoices will be sent via post only. You have the right to change your decision at any time and must re-sign this agreement if you would like to do so.
Your rights
● The laws that protect the privacy and confidentiality of medical information (including HIPAA) apply to information provided via Charm the same as for face-to-face consultation.
Your responsibilities
● Access to the Charm portal is enabled only by usernames and passwords. You are fully and solely responsible for any and all use of the service using your username and password.
● Shafa Psychiatry Center is not responsible for your handling, sharing, re-sharing and/or distribution of your personal health information. If you share personal health information electronically to another person on or off the Charm portal, Shafa Psychiatry Center is not responsible for any harm or other consequences from third party use or re-sharing of your information.
* I have read and understand the information provided regarding Luminello and associated privacy risks, and:
I CONSENT to using the Charm portal to exchange communications that may contain protected health information with
Shafa Psychiatry Center
I DO NOT CONSENT to using the Charm portal to exchange communications that may contain protected health information with Shafa Psychiatry Center
Telepsychiatry
Telepsychiatry is the use of videoconferencing to provide psychiatric evaluation, consultation and treatment. Dr. Khosravi offers telepsychiatry appointments via the online provider VSEE These appointments are conducted using your own electronic device, including cell phones and computers. VSEE is a HIPAA compliant web portal used for doctors and health care professionals to conduct telehealth visits online, and is compatible with any PC, Apple computer, tablet or smartphone.
Telepsychiatry appointments via VSEE will contain protected health information and you must be aware that they are potentially able to be obtained by an outside source if VSEE is hacked. You have the right to change your decision regarding telepsychiatry visits at any time and must re-sign this agreement if you would like to do so.
Your rights
● The laws that protect the privacy and confidentiality of medical information (including HIPAA) apply to telepsychiatry the same as for face-to-face consultation.
● The video conferencing technology (VSEE) used by Shafa Psychiatry Center. is encrypted to prevent unauthorized access to your private medical information.
Your responsibilities
● You, and not Shafa Psychiatry Center are responsible for the configuration of equipment on your electronic device, which is used for telepsychiatry. It is your responsibility to ensure the proper functioning of all electronic equipment before your session begins.
How to get set up
● Shafa Psychiatry Center will send you a link via your phone or email that will allow you to access the VSEE appointment portal at the time of your appointment.
* I have read and understand the information provided regarding telepsychiatry and associated risks of privacy breach, and:
I CONSENT to telepsychiatry visits that may contain protected health information to be arranged with Dr. Khosravi using the VSEE web portal.
I DO NOT CONSENT to telepsychiatry visits to be arranged with Dr. Khosravi using the VSEE web portal.
* Signature (required)