Consent to Telehealth Treatment Untitled Document 1420 Key Highway Baltimore, MD 21230 www.drstevesobelman.com Tel - (410) 230-7800 Tel Direct - (410) 230-7828 Fax - (410) 230-7806 steve@drstevesobelman.com Dr. Steven A. Sobelman, P.A. Consent to Telehealth Treatment This form is an agreement between you and your therapist, Dr. Steven A. Sobelman. By filling in the form and submitting it, you are acknowledging having read, understood, and agree with the “Notice of Privacy Practices (HIPAA),” “Fee Statement,” “Office Policy Statement," and "Telehealth Policy." All of these documents are located on Dr. Sobelman's website and can be downloaded or read online..Patient Responsibility Statement:* I do accept the following statement I do not accept the following statement By filling in my name and emergency information below, I am also attesting to the fact that I am aware that Dr. Sobelman may contact the necessary authorities in case of an emergency. I am also acknowledging that if I believe there is imminent harm to myself or another person, I will seek care immediately through my own local health care provider or at the nearest hospital emergency department or by calling 911.If I have any questions or concerns, I will address them in the comment box (below). If the comment box is left empty, this acknowledges that all my questions/concerns have been addressed.Your Name:* First Last Your Email:* Name of Personal Physician or Psychiatrist:* First Last Personal Physician or Psychiatrist Phone Number:*Contact Name in Case of an Emergency:* First Last Emergency Contact Phone Number:*Date:* MM slash DD slash YYYY Comments: Δ