Telehealth Informed Consent • Jasper Health
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Thank you for choosing Jasper Health Services Florida, LLC (“Jasper Health”)! You are viewing this form because you have elected to receive services from us.

Services Provided

In addition to receiving clinical assessments via telehealth (“Telehealth Services”) from one of our mental health providers (a physician, clinical psychologist, or a clinical social worker), you may receive one or more care management services (the “Virtual CM Services”) from Jasper Health. 

Your clinical assessments may include a Social Determinants of Health (“SDOH”) risk assessment, where your provider will evaluate any non-healthcare needs you may have, including food insecurity, housing insecurity, transportation needs, and utility difficulties. This assessment will be performed the same day as your clinical assessment.

Your provider will determine which of the following Virtual CM services you need based on your initial assessments:

  • Principle Illness Navigation (“PIN”) services: PIN services are provided monthly by our auxiliary staff (under the supervision of your mental health provider), who will provide services such as health education (including self-advocacy skills), assisting you with accessing and navigating your healthcare needs, and provided general behavioral health support. These services are tailored to patients with high-risk, serious illnesses (such as cancer). 
  • Remote Therapeutic Monitoring (“RTM”) services: RTM the collection of non-physiologic health data outside of a clinical setting (for example, while you are at home or at work) and transmission of that data to your healthcare provider for evaluation. RTM devices collect various forms of health data, including medication adherence to monitor patients’ musculoskeletal systems. Your healthcare provider can use this data to monitor your health conditions, provide recommendations, and/or make changes to your care plan.

Your Care Team

Jasper Health takes a collaborative approach to your care. All of your Telehealth and Virtual CM Services are overseen by a clinical psychologist, who will develop your care plan together with  our social worker. Our psychologist and social worker oversee care that you receive from our auxiliary staff, who will provide your CHI or PIN services. Once you begin receiving Virtual CM Services you will be assigned a designated care navigator who will be your central point of contact with us. 

Telehealth vs. Virtual CM Services

Telehealth is the delivery of healthcare services, including examination, consultation, diagnosis, and treatment, through electronic communication technologies when you (the patient) are located in a different location than your healthcare provider. Jasper Health allows you to receive services without having to travel to another location or schedule a separate appointment. This helps you avoid long wait times that you might otherwise experience at an in-person visit.

During your telehealth visit, our mental health practitioners may discuss details of your mental health and medical history and personal health information using interactive video, audio, and telecommunications technology. 

Our Virtual CM Services are not considered telehealth by Medicare and are therefore not subject to the same billing, location, and supervision restrictions as traditional telehealth. 

Benefits of Telehealth and Virtual CM

The benefits of telehealth include having access to healthcare anywhere you have access to the internet—including from the comfort of your home. Telehealth means you do not have to wait several days for an in-person appointment. Telehealth also means you do not have to travel great distances to gain access to specialty care that may not be available in your community.

Our Virtual CM Services allow you to receive additional, ongoing support outside of clinical visits without having to travel to an in-person appointment.

Possible Risks of Telehealth and Virtual CM

As with any mental health and/or medical treatment, there are potential risks associated with the use of telehealth. Jasper Health believes that the chance of any of these risks occurring is very low. 

These risks may include, without limitation, the following:

  • Delays in evaluation, consultation, or treatment may occur due to deficiencies or failures of the equipment or the Internet, which may include poor video and data quality, Internet outages, or other service interruption issues. You may reschedule the visit with your Jasper Health mental health practitioner should these interruptions occur.
  • Security protocols could fail, causing a breach of privacy of personal and mental health information.
  • Because Jasper Health does not have access to your complete mental health or medical records, if you do not disclose to your mental health practitioner a full list of your mental health and/or medical history, including diagnoses, treatments, and medications/supplements, some negative outcomes may occur.
  • Telehealth services are NOT emergency services and your Personal Data (as defined in the Jasper Health Privacy Policy) WILL NOT BE MONITORED 24/7. If you think you are experiencing a mental health emergency, SEEK SERVICES IN YOUR AREA IMMEDIATELY. If you think you are experiencing a medical emergency, CALL 911 IMMEDIATELY.


Your Rights and Acknowledgements

  • You understand that your personal mental health and/or medical information may be shared with other individuals in accordance with the Jasper Health Notice of Privacy Practices and regulations or laws in the state or territory in which you are located. Further, telehealth may involve electronic communication of your personal mental health and/or medical information to remote mental health practitioners who may be located outside of your state.
  • You have the same privacy rights via telehealth that you would have during an in-person visit. 
  • You understand that no results can be guaranteed or assured—you may not achieve the anticipated benefits of the Services.
  • You understand that a variety of alternative methods of mental health and/or medical care may be available to you, and that you may choose one or more of these at any time. 
  • You understand that some information submitted to Jasper Health may be part of your health record, and you may or may not have the right to review and receive copies of certain mental health records that pertain to you. For more information on your right to access your mental health records, please contact us at [email protected]
  • You attest that you are located in Florida and will be present in the state indicated below during all telehealth encounters with Jasper Health.

This Telehealth Informed Consent is valid during your entire treatment with Jasper Health. If you would like to withdraw consent, you must do so prior to receiving any further Services by emailing us at [email protected]. You have the right to withdraw your consent to participate in the Services at any time, and your withdrawal of consent will not affect your right to future care or treatment. You understand that declining or withdrawing consent may limit my services and may not allow for the full benefits of the Services.

Financial Responsibility

You understand that standard charges may apply for the Services. You are responsible for any applicable copayments, deductibles, or other fees as outlined in your insurance plan.


By signing this document, I agree that I have read and understand the terms above, and that I understand the risks and benefits of telehealth. By accepting these terms, I give my informed consent to receive telehealth care under these terms.