Telehealth Informed Consent

1. What is telehealth?

"Telehealth" or "telemedicine" means the delivery of health care services through real-time, interactive audio and video communication, where the patient and provider are at different physical locations. For mental health care, this typically means video therapy sessions over a HIPAA-compliant platform.

Pasadena Clinical Group offers telehealth as an alternative or complement to in-person sessions. You may choose telehealth for any reason — convenience, scheduling, transportation, immune-compromise considerations, or preference.

2. California Business & Professions Code §2290.5 — your rights

California law (Bus. & Prof. Code §2290.5) requires that, before a health care provider delivers telehealth services, you must:

• Be informed of your right to refuse telehealth at any time, without affecting your right to future care, and to choose in-person services instead.
• Receive information about the use of telehealth.
• Be told what to do if your telehealth session is interrupted by technology failure.
• Provide verbal or written informed consent for telehealth services to be delivered. Written consent is recommended and is what this document represents.

By signing the Telehealth Consent form provided at intake, you confirm you have been informed of these rights and consent to telehealth.

3. Your right to refuse or end telehealth

You may refuse telehealth at any time. You may switch to in-person services at any time. Refusing or ending telehealth will not affect your right to future care or to in-person services. Tell us — verbally or in writing — and we will accommodate the change at the next available appointment.

4. Licensure and location requirements

Our clinicians are licensed in California. California licensure permits us to provide telehealth only to patients who are physically located in California at the time of the session. Per California licensure rules, this is not flexible.

Before each session, we confirm your physical location. If you (or either partner) is physically outside California at session time, we cannot proceed with the session. If your travel is occasional, we'll work with you to reschedule. If your travel is frequent or you have moved out of California, we'll work with you to find a clinician licensed in your state, sometimes maintaining co-treatment with our practice as appropriate.

5. Technology requirements and platform

We use a HIPAA-compliant video platform with a Business Associate Agreement (BAA) in place. Standard consumer Zoom is not HIPAA-secure for clinical sessions and we do not use it.

You will need: a private space, a phone or tablet or computer with a working camera and microphone, and a stable internet connection (recommended: 5+ Mbps download/upload). We send a session link before each session. The platform requires no software installation in most cases.

Your privacy at your end: please join from a private location where you cannot be overheard. Headphones are recommended. Do not share session links with others. The platform records nothing by default and we never record sessions without specific written consent.

6. What to do if technology fails

If our connection drops mid-session:

• If we lose video for less than 2 minutes: we typically wait briefly for reconnection.
• If we lose video for more than 2 minutes: we move to phone for the remainder of the hour. You will receive a phone call from us.
• If we cannot re-establish connection: we'll reschedule the remaining time at no cost. You will not be charged for tech-failure-shortened sessions.
• If you cannot reach us at all: our office line, (626) 354-6440, is monitored same-day on weekdays. For emergencies, call 988 or 911.

7. Limitations of telehealth

Telehealth is not appropriate for all situations. Specifically, telehealth is not appropriate when:

• You are in mental health crisis, suicidal, or in immediate danger to yourself or others. For emergencies, call 988 (Suicide and Crisis Lifeline) or 911.
• You are physically located outside California at the session time.
• For couples therapy where intimate partner violence is occurring, particularly when both partners are in the same home.
• When one or both partners are in active intoxication during the session.
• When clinical assessment indicates in-person work is needed (severe symptomatology, complex trauma processing, high-conflict couples where physical safety is in question).

If we determine telehealth is not appropriate for you at any point, we will discuss in-person options or appropriate referrals.

8. Confidentiality in telehealth

Telehealth confidentiality is protected by the same HIPAA, CMIA, and California laws that protect in-person sessions. The mandatory exceptions to confidentiality (CANRA, Tarasoff, elder/dependent abuse, imminent danger to self) apply equally — see Treatment Consent Section 3.

Recording is prohibited. Neither party may record any portion of a telehealth session without explicit advance written consent of all parties involved.

9. Emergency procedures during telehealth

At the start of each telehealth session, we confirm: (a) your current physical location and address; (b) emergency contact; (c) safety planning if there are concerns. If a clinical emergency arises during a telehealth session, we may: contact emergency services at your location; notify your emergency contact; coordinate a wellness check; or facilitate hospitalization. The aim is your safety; the protocol is documented and discussed in advance.

10. Insurance and reimbursement for telehealth

Most California insurance plans now reimburse telehealth at parity with in-person services per California's payment-parity law. Some plans have specific telehealth requirements (e.g., audio-video required vs. audio-only). We verify telehealth coverage with your plan and advise of any out-of-pocket implications before sessions begin.

11. Telehealth-specific assumption of risk; technology disclaimer

You acknowledge and agree that telehealth carries risks that differ from in-person care, including but not limited to: video, audio, or connection quality issues; transmission interruption or delay; loss of confidentiality due to a household member or co-located individual overhearing the session at your end; loss of confidentiality due to internet-service-provider activity logging or aggregator metadata; and inability of the clinician to perform certain components of clinical assessment that depend on shared physical presence.

Technology disclaimer. The Practice contracts with a HIPAA-compliant telehealth platform under a Business Associate Agreement. The Practice does not warrant the platform's continuous availability, freedom from defects, or absolute security. Liability for platform failure, data interception or breach, or third-party network failure that is not the result of the Practice's gross negligence is allocated to the platform vendor under its BAA, and to the parties at fault, and not to the Practice or the Released Parties. To the maximum extent permitted by Applicable Law, you assume the risk of telehealth-specific harms not caused by the Practice's professional negligence.

Out-of-California disclaimer. California licensure does not extend to delivery of telehealth to a patient physically located outside California. If you (or either partner) is outside California at session time, the session cannot proceed. The Practice is not responsible for any consequence of an interrupted or rescheduled session caused by your out-of-California location, and the cancellation policies in Office Policies apply. The Practice may require photo or geolocation evidence of California presence for sessions where there is reasonable doubt.

12. Limitation of liability and indemnification for telehealth-specific matters

Released Parties has the meaning given in the Office Policies Section 16. To the maximum extent permitted by Applicable Law, you release the Released Parties from claims arising out of telehealth-specific risks described in §11 (other than those caused by the Practice's professional negligence, which are governed by the dispute-resolution provisions of §13 below). This release does not extend to any claim that under Applicable Law cannot be released.

You agree to indemnify and hold harmless the Released Parties from claims arising out of (a) your knowing failure to disclose your physical location at session time; (b) your unauthorized recording of a session in violation of Cal. Penal Code §632; (c) your failure to maintain a private session environment that you have certified to the clinician; or (d) your sharing of session links with unauthorized third parties. The Released Parties' aggregate liability for telehealth-specific non-clinical claims is limited to the fees paid for telehealth services in the twelve (12) months preceding the event giving rise to the claim. Nothing in this Section limits liability for claims that cannot be limited under Applicable Law, including liability for the Practice's professional negligence, gross negligence, willful misconduct, or violation of CCPA/CPRA, CMIA, HIPAA/HITECH, or any non-waivable consumer-protection statute.

13. MANDATORY DISPUTE RESOLUTION FOR TELEHEALTH CARE — NEGOTIATION → MEDIATION → BINDING ARBITRATION

This Section applies to all disputes arising out of or relating to telehealth services rendered by the Practice (a "Telehealth Dispute"), including claims of professional negligence, breach of professional duty, lack of informed consent, intentional or negligent infliction of emotional distress arising from telehealth care, billing-and-coding disputes related to telehealth services, and any other claim arising out of or relating to the rendition of telehealth services to the patient (including the death of a patient). Telehealth Disputes are governed by the FAA (9 U.S.C. §§1–16) and Cal. Code Civ. Proc. §1295. The procedural steps and protections of §15 of the Treatment Consent are incorporated by reference and apply to Telehealth Disputes, except that any reference to "the Practice" in §15 of the Treatment Consent shall be read to include telehealth-specific Released Parties (the platform vendor and the patient's choice of residential clinical site, where applicable, are not Released Parties absent an executed BAA).

13.1 Step one — informal good-faith negotiation

The party raising the Telehealth Dispute provides written notice to the other party describing the dispute and the relief sought. The parties negotiate in good faith for thirty (30) days. Compliance is a condition precedent to mediation and arbitration.

13.2 Step two — mandatory mediation

If unresolved within thirty (30) days, the parties mediate before a single neutral mediator administered by JAMS in Los Angeles County, California, under JAMS' then-current rules. Costs are split equally; each party bears its own attorneys' fees. Mediation lasts at least one (1) full session of at least four (4) hours unless the mediator declares earlier impasse. Completion (or impasse declaration) is a condition precedent to arbitration.

13.3 Step three — final and binding arbitration

If mediation does not resolve the dispute, it shall be submitted to final and binding individual arbitration administered by JAMS in Los Angeles County, California, under JAMS' Healthcare Arbitration Rules and Procedures (or, if unavailable, the JAMS Comprehensive Arbitration Rules). The arbitrator is a single neutral retired California judge or a California-licensed attorney with at least fifteen (15) years of healthcare or professional-negligence experience. The arbitrator shall apply California substantive law and shall issue a written, reasoned, final and binding award; judgment may be entered in any court of competent jurisdiction. Confidentiality, fee allocation, and consumer-arbitration minimum standards apply as set forth in §15 of the Treatment Consent.

13.4 Class-action and representative-action waiver

To the maximum extent permitted by Applicable Law, all Telehealth Disputes shall be resolved on an individual basis. The arbitrator may not consolidate more than one person's claims and may not preside over any class, representative, mass, or consolidated proceeding. If a court determines this waiver is unenforceable as to any specific claim, that claim is severed and proceeds in court while all other claims remain in arbitration.

13.5 Carve-outs

• Sexual assault or sexual harassment claims subject to the federal EFAA (9 U.S.C. §§401–402);
• Mandatory reporting by the Practice (CANRA, elder/dependent abuse, Tarasoff) is an obligation, not a Dispute;
• Government-agency complaints (BBS, AG, DCA, HHS-OCR, CRD, EEOC, etc.) are always permitted;
• Small claims within Los Angeles County limits, on an individual basis;
• Equitable relief in a court of competent jurisdiction in Los Angeles County for trade secrets, copyrights, or confidentiality;
• Workers' compensation and other claims that under Applicable Law cannot be subjected to pre-dispute arbitration.

13.6 Mandatory; survival; coordination with Treatment Consent

This Section 13 is mandatory; the only opt-out is the §1295 statutory rescission right. This Section 13 survives termination of the telehealth relationship and operates in parallel with §15 of the Treatment Consent. To the extent any conflict exists between this Section and §15 of the Treatment Consent, the Treatment Consent controls for clinical-care matters, and this Section 13 controls for telehealth-specific matters. Nothing in this Section permits the Practice to deny in-person care to a patient who declines telehealth.

14. Acknowledgment

By signing the Telehealth Consent form provided at intake, you acknowledge that you have:

• Read this consent (or had it explained to you).
• Been informed of your rights under California Bus. & Prof. Code §2290.5.
• Been informed of the technology, location, and emergency requirements.
• Read the §1295 Notice of Arbitration Agreement and understand your statutory thirty-day rescission right.
• Had the opportunity to ask questions.
• Voluntarily agreed to receive telehealth services with these limits.

Both partners (and any custodial parent for minors) must sign before the first telehealth session.

15. Contact us

Pasadena Clinical Group
301 N. Lake Ave, STE 600
Pasadena, CA 91101
Email: office@pasadenaclinicalgroup.com
Phone: (626) 354-6440

Telehealth: available 7 days a week, including evenings and weekends.