Limited HIPAA and 42 CFR Part 2 Consent and Authorization  to Release Personal Healthcare Information During Telehealth Group Therapies

I, the undersigned client, authorize The PRISM Center to share my audio and/or verbal participation with:

Current group therapy members who are participating in group therapy via telehealth technology (Zoom, Facetime, Cisco web), due to the Corona Virus Outbreak.

Description of Information to be Disclosed

My audio/verbal and visual participation in group therapy via telehealth technology services (Zoom).


The purpose of this authorization and disclosure of information is to continue group therapy services in a temporary global, national, city wide corona virus health emergency/disaster. I understand this is to enable myself/group members who cannot attend therapy in person due in some way to the corona virus pandemic to continue accessing medically necessary treatment group therapy and Intensive Outpatient Programming treatment.

Group Therapy Via Telehealth Will ONLY Be Available Under The Following Conditions and Guidelines:

  1. The technology options available to The Prism Center and Ethos Behavioral Health affiliates are Zoom and Facetime. They are privacy optimized. None of these entities will record or store data. The technology is only used to enable groups of people to participate via audio or audio/visual means. Zoom has signed a Business Associates Agreement (BAA) with Ethos Behavioral Health/Prism. Facetime does not sign any BAAs with any user/provider.

I understand using this technology does NOT guarantee my health information/participation will remain private.

  1. Every client/patient has a right to decline participating in a group therapy session that has members attending via remote telehealth technology.
  1. If a client/patient wants to participate remotely via telehealth technology, he/she will need to agree to the following guidelines to maximize the privacy and protection of private health/personal information of themselves and their fellow peers:
  • A remote participant shall only participate at home, in a private room, with a door shut, ensuring no interruptions by any other persons who may enter the environment. No recording of sessions shall occur. Every effort shall be made to ensure others cannot overhear the telehealth session;
  • No members shall use their last name nor the last name of a peer during group to facilitate anonymity. No information shall be disclosed that can easily identify a group member;
  • The therapist will immediately discontinue the remote hook up/call if another person is seen or heard in the remote group member’s environment;
  • If any group members do not give permission to include a member via remote technology, then the remote member cannot participate in the group session;
  • Client agrees and understands that a telehealth session may be terminated at any time if it appears there is a confidentiality issue. This may happen without notice;
  • Client agrees that if technical issues prevent effective participation, the telehealth session may be ended, and that group discussions will not be interrupted to address technical issues;
  • It is highly recommended that remote participants use ear buds or ear phones to further block group participants verbiage from being heard in remote environments.

I understand that although my remote peers agree to protect the privacy of the group therapy and that of all peers attending in person or remotely, my privacy and the protection of my words, others may see or overhear the group therapy session and the technology does not guarantee protection of personal/health information that I/others disclose.

I understand that if I agree to participate in a telehealth group therapy, I am waiving some of my HIPAA protections of my health information. Again, I do not have to agree to participate in telehealth group therapy – it is optional.

  1. Revocation: This consent and authorization will remain in place until revoked by the client/patient. He/she may revoke this consent/authorization at any time, for any reason, or no reason at all. Revocation can be done verbally by notifying the group therapist, or by text, email, or noting in on the originally signed consent/authorization. Date/time of revocation is to be duly noted by the therapist. The terms of the client’s service with Prism/Ethos will not be affected if the client chooses not to sign a consent nor if consent is revoked at a later date.
  1. Expiration: Unless revoked sooner, this authorization will expire one (1) year from date of client discharge from all PRISM services.
  1. If requested, I will be given a copy of this authorization for my records.

If you are signing for a child or person for whom you are a legal guardian or from whom you have a power of attorney, please sign below to fully consent and authorize the Prism Center to use your child or ward’s private health information as detailed above.