Limited HIPAA and 42 CFR Part 2 Consent and Authorization  to Release Personal Healthcare Information During Telehealth Individual/Family/Couples Therapies

I, the undersigned client, want to participate in telehealth Individual, Family, and Couples Therapy

provided by therapists at The PRISM Centers in Bellaire and/or Cypress, TX.  Prism is a subsidiary of Ethos Behavioral Health, LLC. Telehealth therapy will be conducted through the technologies of Zoom or Facetime, and will entail me sharing my personal and health information in the form of verbal/audio or verbal/audio/video self-disclosure participation.

Description of Information to be Disclosed

My audio/verbal and possibly visual participation/self-disclosures in Individual, Family, and Couples Therapy will be via telehealth technology services hosted by Zoom and Facetime.


The purpose of this authorization and disclosure of information is to continue therapies currently restricted in face-to-face format due to a temporary global, national, and citywide corona virus health emergency/disaster. I understand this technologically-assisted therapy is to enable myself in accessing medically necessary treatment.

These Telehealth Therapies 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 multiple individuals 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. Each client/patient has a right to decline participating in telehealth therapy sessions.
  2. 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 any family members that may participate in sessions:
  • All telehealth participants 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;
  • The therapist or client/patient may immediately discontinue the remote hook up/call if another person is seen or heard in either party’s environment;
  • If any partner or family member is not comfortable engaging in a telehealth session, then it will not be conducted by the therapist.
  • 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 the telehealth session will not be interrupted to address technical issues;
  • It is highly recommended that remote participants use ear buds or ear phones to further block telehealth participants’ verbiage from being heard in remote environments.
  • I understand that although I have agreed to participating in telehealth therapies, my privacy and the protection of my words/video presence, and that of other family members and the therapist, are not guaranteed.

I understand that if I agree to participate in a telehealth therapies, I am waiving some of my HIPAA protections of my health information. Again, I do not have to agree to participate in telehealth therapies – they are 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 therapist, or by text, email, or noting it 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/Ethos services.
  2. 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.