Telepsychiatry Consent Form for Current Patients/Caregivers

Telepsychiatry allows Dr. Candice Boley to provide psychiatric services using an interactive video conferencing tool, Doxy.me, VSee or Microsoft Teams, in which Dr. Boley and the patient (and/or caregiver) are not at the same location. Telepsychiatry will allow the patient to receive medical care without the need to visit the office. 

Potential Risks include, but may not be limited to:

• Information transmitted may not be sufficient (i.e. poor audio or resolution of video) to allow for appropriate medical decision making by Dr. Boley.
  
• Delays in medical evaluation and treatment due to deficiencies or failures of the equipment.
• Dr. Boley may not be able to provide medical treatment to the patient using interactive electronic equipment nor provide for or arrange for emergency care that the patient may require, in cases of connection failure.
• Security protocols can fail, causing a breach of privacy.
• Lack of access to all the information available in a face-to-face visit may result in errors in medical judgment. 

Your Rights: 

• I understand that the laws that protect the privacy and confidentiality of medical information also apply to telepsychiatry.
  
• I understand that Doxy.me and VSee are known to incorporate network and software security protocols to protect the confidentiality of information and audio/visual data. These protocols include measures to safeguard the data and to aid in protecting against intentional or unintentional corruption. You can review the security features of Doxy.me at ​https://www​.doxy.me , the features of VSee at https://vsee.com/ , or the features of Microsoft Teams at https://teams.microsoft.com.
  
• I have the right to withdraw my consent to the use of telepsychiatry during the course of my care at any time. 
• I understand that Dr. Boley 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 all rules and regulations which apply to the practice of medicine in the State of Washington also apply to telepsychiatry. 

Your Responsibilities:

• I will not record any telepsychiatry sessions without the prior written consent of Dr. Boley and I understand that Dr. Boley will not record telepsychiatry sessions without my consent.
• I will inform Dr. Boley if any other person can hear or see any part of our session before the session begins. Likewise, Dr. Boley will inform me if any other person can hear or see any part of the session before the session begins. 
• I understand that I MUST be a resident of Washington to be eligible for telepsychiatry services from Dr. Boley. 
• I consent to paying fees that are the same as in office visits for the type and length of services provided.
  
• I understand that a telepsychiatry appointment is scheduled the same as an in-office appointment and that no shows and last-minute cancellations (i.e. less than 48 hours in advance) will be charged as a missed appointment for the time Dr. Boley has reserved for a scheduled appointment.

Your signature (or verbal consent provided) indicates that you have read and understand the information provided above regarding telepsychiatry, and that you authorize Dr. Boley to use telepsychiatry in the course of diagnosis and treatment.

Candice Boley, MD

To reach Dr. Candice Boley, please call 206-329-0734. Send a fax to Dr. Boley at 206-946-8171.

(she/her)

Lake Union Psychiatric Group

TELEPSYCHIATRY/TELEHEALTH APPT

• Please call me if you have questions or concerns in advance of appt re: telepsychiatry and the consent form.
  
• At least few minutes in advance of our appt, please access Doxy.me/drboley, using Chrome, Firefox or Safari for your web browser, and enable camera and audio. You will be asked to type your name (first name is fine, it will identify to me that you are online). If you plan to use your phone, please test out your phone’s browser to make sure it works. You do NOT need to set up an account.
• I will initiate the call once we are both online and when I am ready. If I am running behind, I may send you a message via the website indicating I am late.
• Please plan to speak in a location in which you have some privacy, and do not mind part of your background showing on screen.
  
• If we have trouble with connecting, we will try calling one another. My direct line: 206-329-0734. Vsee and Microsoft Teams are my back-up options if Doxy.me is not working.
  

I am a psychiatrist specializing in the evaluation and treatment of children, adolescents and adults. I opened my private practice in 2012 after completing my Adult Psychiatry Residency and Child and Adolescent Psychiatry Fellowship at the University of Washington Medical Center/Seattle Children’s Hospital. I obtained my medical degree from the University of Michigan Medical School, and am board-certified in both adult/general psychiatry and child and adolescent psychiatry.

I provide diagnostic evaluations, consultation services, and individualized treatment. My treatment approach is tailored to you or your child, and may include medication management, as well as cognitive behavioral therapy, supportive therapy, insight-oriented therapy and psychoeducation.

My areas of expertise include anxiety and depression, OCD, social anxiety, stress management, life transitions, adjusting to parenthood, returning to work, interpersonal relationship issues, work-life balance, coping with medical illness, caring for a family member with medical issues, and grief and loss.

After a brief phone consultation, we will determine if we may be the right fit for one another, and schedule an initial appointment.
 
I hope to help you gain more understanding of (and modify) how your experiences and emotional, thought and behavioral patterns influence your life. I strive to support you in achieving your goals in a compassionate and warm environment.

Regarding health insurance, I am in network for Regence, Uniform Medical Plan, Premera Blue Cross, Lifewise and most Blue Cross/Blue Shield plans. I am out of network for all other insurance plans.