FORM – Telepractice Consent Form

Musser Voice/Musser Therapies, LLC, offers clients the opportunity to have their voice/speech evaluation and treatment via the use of telepractice (i.e. the use of the internet).

Providing services over the internet, however, has a number of risks that clients should consider before deciding if telepractice is the right option for them. These include, but are not limited to, the following:

• the sessions could possibly be intercepted by external sources or people;
• private and personal information may be accessed by those who intercept; or
• the computers used for telepractice could be infected by a virus.

Despite these risks, we have taken all necessary steps to ensure the highest possible confidentiality and privacy protection for all clients served by telepractice. This includes use of professional, secure telemeeting software (Zoom), which was chosen for its ease, consistency and security features.

Additional technical defenses have also been deployed by Musser Voice/Musser Therapies, LLC including:

• all computers used for the telepractice sessions have appropriate anti-virus and anti-spyware protection to prevent eavesdropping during sessions;
• all computers are password protected;
• a wired internet connection is used for all sessions; and
• all clinicians involved in provision of services by telepractice have received training related to HIPAA privacy and confidentiality issues.

To further protect your privacy and confidentiality, during the sessions your clinician may:

• scan the room with a video camera prior to treatment to show you that he or she is alone in the room during sessions;
• ask you to inform them right away if you think that your confidentiality or privacy has been violated [e.g. if you hear background noise during the videoconferencing];
• video-record the session for fidelity and reliability measurements;
• or ask you to agree to never share or open links to external webpages during the telepractice sessions.

By signing this document, I acknowledge that I have read and fully understand the information Musser Voice/Musser Therapies, LLC has provided me regarding the risks of telepractice. I understand the risks and consent to the conditions outlined herein. In addition, I agree to the instructions outlined. My signature indicates my consent for the provision of services via telepractice.