TeleHealth Patient Forms

Authorization Form
Neuropsychology Associates of Fairfax (NAF) is offering neuropsychological evaluation
services using telehealth and videoconferencing. We are implementing telehealth to facilitate the
provision of our services in the safest possible way during the COVID-19 pandemic. Making use
of videoconferencing is possible because of changes in billing where Medicare and other
insurance carriers are now reimbursing the use of telehealth methods in the provision of
neuropsychological assessments and due to the accumulation of research supporting the use of
neuropsychological services offered remotely.

Providing for assessments using telehealth means that the patient and examiner will be at
different locations and that they will be connected with each other using videoconferencing. The
initial interview will be conducted remotely using videoconferencing and other family members
may be present with the patient to provide information. This is similar to in-person visits where
friends or family members may accompany the patient to provide information. Once the
evaluation and testing starts, no family member can be present. The patient will be informed if
any additional NAF staff member is present other than the examiner. The patient may request at
any time for the additional NAF staff person to not be present during the evaluation. It is
important that the patient be in a private, comfortable, quiet, and well-lit room with no
distractions. The patient should also have a desk or table where he or she can write.

The examiner doing the testing will ask the patient to perform certain tasks that require different
cognitive skills. The examiner may also show the patient different pictures that will be presented
on the patient’s video monitor. If the picture does not look clear, or if it is hard to understand the
examiner, the patient should tell the examiner immediately. Neither patients nor individuals who
may be located in the same place as the patient are allowed to copy or record any portion of the
examination. This includes taking screen shots of test materials. Copying test materials violates
copyright laws and is illegal. Any productions made by the patient (things written or drawn)
cannot be kept or copied. Productions must be sent back to NAF or destroyed. These productions
cannot be shared with any other individual and may also constitute a copyright violation in that
they may be drawings of protected material. Protecting test materials is required by law and is
necessary to ensure their continued validity.

NAF will not be recording any part of the telecommunications. However, there will be instances
where the doctor, examiner or administrative staff will need to take a screen shot (still picture).
This will include (but not limited to) taking a still shot of the patient to verify against
identification to validate identity; taking a still shot of pages the patient has written on as part of
their testing materials.

Similar to making an in-office visit, patients will be asked to provide personal identification to
NAF staff and to complete forms related to obtaining background information and billing. Other
administrative forms must be completed such as releases of information that allow us to send the
report of your examination to referring physicians and others who you designate. Separate
release of information forms also allow us to obtain information from referring health providers.
You will be given information regarding regulations and your rights under the Health Insurance
Portability and Accountability Act (HIPAA).
To accomplish the in-home assessment via telehealth in a manner that meets HIPAA standards,
NAF will use HIPAA compliant technology making use of end-to-end encryption. NAF cannot
guarantee Internet transmission against all threats. NAF will ensure our approach to remote
evaluations meets required standards. The examination will not be recorded without your
separate written permission. All documents and test results produced by the assessment will be
held securely by NAF in the same manner as if the evaluation was taking place in-person.

NAF views telehealth as a method to safely and conveniently provide neuropsychological
evaluations. Research data indicates that examinations can be done remotely obtaining accurate
data that can benefit patients and their referring healthcare providers, At this point in time not
every test available for in-office administration is available via telehealth. We also believe it is
important to reduce the time of testing when it is done remotely and provided in-home. Patients
may elect not to engage in evaluations via telehealth and instead request an in-office appointment
as these appointments become available. We may also schedule an in-office appointment as a
follow-up to an in-home telehealth visit.

The ability to carry out online assessment depends on having a reliable Internet connection with
transmission adequate for conversation and test administration. If a patient does not have a
workable Internet connection, we will schedule an in-office visit. If the Internet connection is
disrupted or degrades, we wil] attempt to re-establish the connection. If re-establishing the
connection does not work, we will reschedule the telehealth appointment at a different time or
schedule an in-office visit as in-office visits become available.

I have read the above information and agree to all indicated stipulations. I have been given time
to ask questions. I agree to undergoing a remote evaluation using video conferencing.

To Book an Appointment Call: (703) 876-0966 option 1

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