Tele-Behavioral Health State-Specific Disclosures
Last updated: 12/30/2024
Alaska
You understand that your primary care provider may obtain a copy of your records of your telehealth encounter.
This document is intended to provide you with all of the information is required by the Board of Professional Counselors which regulates all licensed professional counselors. You may contact the Board with any questions or concerns. Alaska Stat. § 08.63.210(c)(2).
Board of Professional Counselors
Division of Corporations, Business & Professional Licensing
P.O. Box 110806 Juneau, AK 99811-0806 Phone: (907) 465-2551
Email: ProfessionalCounselors@Alaska.Gov
Arizona
You are entitled to all existing confidentiality protections, including where a provider may only disclose all or part of your medical record and payment record as authorized by state or federal law or written authorization signed by you or your health care decision maker, pursuant to A.R.S. § 12-2292. You also understand all medical reports resulting from the telemedicine consultation are part of your medical record as defined in A.R.S. § 12-2291. You also understand dissemination of any images or information identifiable to you for research or educational purposes shall not occur without your consent, unless authorized by state or federal law. Ariz. Rev. Stat. Ann. § 36-3602(D).
Board of Behavioral Health Examiners
1740 West Adams Street, #3600
Phoenix, AZ 85007
Main Number: 602-542-1882
Fax Number: 602-364-0890
information@azbbhe.us
Colorado
You are entitled to the consent requirements outlined under 2 CO ADC 502-1:21.170.4. The confidentiality of your individual records, including all medical, mental health, substance use, psychological, and demographic information shall be protected with the applicable state and federal laws and regulations, as provided under 2 CO ADC 502-1:21.170.2. 2 CO ADC 502-1:21.170.2.
State Board of Licensed Professional Counselor Examiners, State Board of Social Work Examiners, State Board of Marriage and Family Therapist Examiners, State Board of Addiction Counselor Examiners, and State Board of Psychologist Examiners
1560 Broadway, Suite 1350, Denver, Colorado 80202, (303) 894-7800
Email: DORA_Customercare@state.co.us
Connecticut
You understand that each telehealth provider shall, at the time of the initial telehealth interaction, ask you whether you consent to that provider’s disclosure of records concerting the telehealth interaction to your primary care provider. You further understand that your primary care provider may obtain a copy of your records of your telehealth encounter, upon your consent. Conn. Gen. Stat. Ann. § 19a-906(d).
Connecticut Department of Public Health
Professional Counselor Licensure
410 Capitol Ave., MS #12 APP
P.O. Box 340308
Hartford, CT 06134
Phone: (860) 509-7603
Fax: (860) 707-1980
Email: dph.counselorsteam@ct.gov
District of Columbia
You have been informed of alternate forms of communication between you and a physician for urgent matters. D.C. Mun. Regs. tit. 17, § 4618.10. Relevant communications with the physician, including those done via electronic methods shall be documented and filed in your medical record. D.C. Mun. Regs. tit. 17, § 4618.9.
Professional Counseling Licensing
899 North Capitol Street, NE, Washington, DC 20002
Phone: (202) 442-5955
Fax: (202) 442-4795
Department of Health Board of Medicine
899 North Capitol Street, NE
Washington DC, 20002
Email: doh@dc.gov
Georgia
You have been given clear, appropriate, accurate instructions on follow-up in the event of needed emergent care related to the treatment. Ga. Comp. R. & Regs. 360-3-.07(a)(7).
Georgia Composite Medical Board
2 Peachtree Street, NW
6th Floor
Atlanta, GA 30303-3465
Email: medbd@dch.ga.gov
Idaho
If you need to register a formal complaint about a physician, you may visit the medical board’s website, here. Idaho Guidelines for Appropriate Regulation of Telemedicine. You further understand that your informed consent for the use of telehealth services shall be obtained by applicable law. Idaho Statutes 54-5708.
Board of Medicine: Logger Creek Plaza
345 Bobwhite Ct., Suite 150
Boise, ID 83706
Division of Professional Licenses: 11351 W. Chinden Blvd., Bldg. #6
Boise, ID 83714
Indiana
If a prescription is issued to you, and subject to your consent the prescriber shall notify your primary care provider of any prescriptions the prescriber has issued for you if the primary care provider's contact information is provided by you. This requirement does not apply if: (A) The practitioner is using an electronic health record system that your primary care provider is authorized to access. (B) The practitioner has established an ongoing provider-patient relationship with the patient by providing care to the patient at least 2 consecutive times through the use of telehealth services. If the conditions of this clause are met, the practitioner shall maintain a medical record for you and shall notify your primary care provider of any issued prescriptions. Ind. Code Ann. 25-1-9.5-7.
Professional Licensing AgencyAttn: [insert relevant profession]402 W. Washington Street, Room W072Indianapolis, Indiana 46204
Email: pla3@pla.in.govPhone Number: (317) 234-2060
Iowa
To file a complaint, fill out the complaint form and email it to the medical board at ibmcomplaints@iowa.gov. Iowa Admin. Code 653-13.11(147,148,272C)(13.11(18)).
As appropriate your provider will identify the medical home or treating physician(s) for you, when available, where in-person services can be delivered in coordination with the telemedicine services. Your provider shall provide a copy of the medical record to your medical home or treating physician(s). Iowa Admin. Code 653-13.11(147,148,272C)(13.11(11)).
Iowa Board of Medicine
Dept. of Inspections, Appeals, & Licensing
6200 Park Avenue
Suite 100
Des Moines, IA 50321
Kansas
You understand that if you have a primary care or other behavioral health treating provider and if you consent to us sharing your information with such provider, then we are obligated to send within three business days a report to such primary care or other treating physician of the treatment and services rendered by Jimini Health during the telemedicine encounter. Kan. Stat. Ann. § 40-2,212(2)(d)(2)(A).
Kansas Board of the Healing Arts
800 SW Jackson, Lower Level - Suite A, Topeka, KS 66612
(785) 296-7413; Fax (785) 368-7102
Kentucky
You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here:
https://kbml.ky.gov/board/Pages/default.aspx.
If requested by you, your physician must share the medical record with your primary care physician and other relevant members of your existing care team. Kentucky Board Opinion on the Use of Telemedicine Technologies (2014), as amended September 15, 2022.
Kentucky Board of Medical Licensure
310 Whittington ParkwaySuite 1BLouisville, KY 40222
Louisiana
You understand the role of other health care providers that may be present during the consultation, other than the Jimini Health provider. 46 La. Admin. Code Pt XLV, § 7511.
Licensed Professional Counselors Board of Examiners
11410 Lake Sherwood Ave North Suite A
Baton Rouge, LA 70816
225-295-8444 (phone)
225-295-8448 (fax)
lpcboard@lpcboard.org
Maine
If you have a concern or complaint about the mental health professionals providing care to you, you may contact a board agency to assist you.
If you want to register a formal complaint about a physician, you should visit the medical board’s website, here:
https://www.maine.gov/md/complaint/file-complaint
Code Me. R. tit. 02-373 Ch. 11, § 3.
Complaint Coordinator Office of Licensing and Registration
35 State House Station Augusta, ME 04333
Tel: (207) 624-8660
www.maine.gov/professionallicensing
New Hampshire
You understand that the provider may forward your medical records to your primary care or treating provider. N.H. Rev. Stat. § 329:1-d.
Office of Professional Licensure & Certification
7 Eagle Square
Concord NH, 03301
Phone: 603-271-2152
New Jersey
You understand that you have the right to request a copy of your medical information and you understand your medical information may be forwarded directly to your primary care provider or health care provider of record, or upon your request, to other health care providers. If you do not have a primary care provider or other health care provider of record, the health care provider engaging in telemedicine or telehealth may advise you to contact a primary care provider, and, upon request by you, may assist you with locating a primary care provider or other in-person medical assistance that, to the extent possible, located within reasonable proximity to you. N.J. Rev. Stat. Ann. § 45:1-62.
New Jersey Board of Medical Examiners
bme@dca.lps.state.nj.us
(609) 826-7100
Professional Counselors Examiners
MFTinquiries@dca.njoag.gov
(973) 504-6582
Ohio
You understand that the provider may forward your medical records to your primary care or treating provider. Ohio Admin. Code 4731-37-01(C)(4).
Ohio Medical Board
Complaints may be sent to: complaints@med.ohio.gov or call the Medical Board at 614-466-3934 and choose option 1 to speak to the complaint department.
You may also leave a message on the State Medical Board of Ohio's Confidential Complaint Hotline at 1-833-333-SMBO (7626).
Oregon
If you have a concern or complaint about the mental health professionals providing care to you, you may contact a board agency to assist you. You understand that the provider may ask if you need more detail. ORS 17-52-677.07
The Board of Licensed Professional Counselors and Therapists 3218 Pringle Rd SE, #120,
Salem, OR 97302-6312
Telephone: (503) 378-5499 Email: lpct.board@state.or.us
Website: www.oregon.gov/OBLPCT
Rhode Island
If you use e-mail or text-based technology to communicate with your provider, then you understand the types of transmissions that will be permitted and the circumstances when alternate forms of communication or office visits should be utilized. You have also discussed security measures, such as encryption of data, password protected screen savers and data files, or utilization of other reliable authentication techniques, as well as potential risks to privacy. You acknowledge that your failure to comply with this agreement may result in the telehealth provider terminating the relationship. Rhode Island Medical Board Guidelines.
Rhode Island Board of Medical Licensure and Discipline
Department of Health
3 Capitol Hill, Room 401
Providence, RI 02908
Phone: (401) 222-3855
Fax: (401) 222-2158
Pennsylvania
You understand that you may be asked to confirm your consent to behavioral health or telepsychiatry services. 40 PS §1303.504(b).
State Board of Social Workers, Marriage and Family Therapists and Professional Counselors
P.O. Box 2649, Harrisburg, PA 17105-2649 717-783-1389
South Carolina
The information you share in psychotherapy is protected health information and is generally considered confidential by both South Carolina state law and federal regulations, with some limited exceptions (e.g., may be shared with another healthcare provider, required by subpoena). Your mental health practitioner is also mandated by standards - through Duties to Warn - to breach confidentiality if: (1) you are threatening self-harm or suicide; (2) you are threatening to harm another or homicide; (3) a child has been or is being abused or neglected; and/or (4) a vulnerable adult has been or is being abused or neglected. S.C. Code 40-75-190.
You understand your medical records may be distributed in accordance with applicable law and regulation to other treating health care practitioners. You understand the value having of having a primary care medical home and, if requested, we can provide assistance in identifying available options for a primary care medical home. S.C. Code Ann. § 40-47-37.
South Carolina Board of Examiners for The Licensure of Professional Counselors, Marriage and Family Therapists, and Psycho-educational Specialists
P.O. Box 11329,
Columbia, South Carolina 29211-1329 Telephone: 803-896-4652
South Dakota
You have received disclosures regarding the delivery models and treatment methods or limitations. You have discussed with the telehealth provider the diagnosis and its evidentiary basis, and the risks and benefits of various treatment options. S.D. Codified Laws § 34-52-3.
South Dakota Board of Medical & Osteopathic Examiners
101 N. Main Ave Suite 301
Sioux Falls, SD 57104
E-mail: SDBMOE@STATE.SD.US
Phone: 605-367-7781
Tennessee
You understand that you may request an in-person assessment before receiving a telehealth assessment if you are a telehealth recipient. TN Dept. of Mental Health and Substance Abuse Services. Office of Crisis Services Telecommunications Guidelines, p. 8, (2012) (Accessed Jan. 2024).
The information you share in psychotherapy is protected health information and is generally considered confidential by both Tennessee state law and federal regulations, with some limited exceptions (e.g., may be shared with another healthcare provider, required by subpoena). Your mental health provider may also disclose information without consent: (1) if disclosure is necessary for other duties that the mental health provider is bound by, (2) if it is necessary to assure service or care is the least drastic means, (3) due to a court order, (4) if it is solely information to a residential service recipient, (5) to facilitate continuity of service to another health care provider, (6) if a custodial agent for another state agency that has legal custody of the service cannot perform the agent’s duties, or (7) it is necessary for the preparation of a post-mortem examination. Tenn. Code Ann. §33-3-105.
Tennessee Department of Health
710 James Robertson Parkway
Nashville, TN 37243
E-mail: tn.health@tn.gov
Texas
You understand that your medical records may be sent to your primary care physician within 72 hours. Tex. Occ. Code Ann. § 111.005.
You have been informed of the following notice:
NOTICE CONCERNING COMPLAINTS -Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board may be reported for investigation at the following address: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Assistance in filing a complaint is available by calling the following telephone number: 1-800-201-9353, For more information, please visit our website at www.tmb.state.tx.us.
AVISO SOBRE LAS QUEJAS- Las quejas sobre médicos, asi como sobre otros profesionales acreditados e inscritos del Consejo Médico de Tejas, incluyendo asistentes de médicos, practicantes de acupuntura y asistentes de cirugia, se pueden presentar en la siguiente dirección para ser investigadas: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Si necesita ayuda para presentar una queja, llame al: 1-800-201-9353, Para obtener más información, visite nuestro sitio web en www.tmb.state.tx.us
Utah
You are able to a (i) access, supplement, and amend your patient-provided personal health information; (ii) contact your provider for subsequent care; (iii) obtain upon request an electronic or hard copy of your medical record documenting the telemedicine services, including the informed consent provided; and (iv) request a transfer to another provider of your medical record documenting the telemedicine services. Utah Admin. Code r. 156-1-602.
Utah Medical Board
(801) 530-6628
(866) 275-3675
b1@utah.gov
Virginia
You acknowledge that you have received details on security measures taken with the use of telemedicine services, such as encrypting date of service, password protected screen savers, encrypting data files, or utilizing other reliable authentication techniques, as well as potential risks to privacy notwithstanding such measures; You agree to hold harmless Jimini Health for information lost due to technical failures; and you provide your express consent to forward patient-identifiable information to a third party. Virginia Board of Medicine Guidance Document 85-12.
Virginia Department of Health ProfessionsEnforcement DivisionPerimeter Center9960 Mayland Drive, Suite 300Henrico, VA 23233-1463
Telephone: 1-800-533-1560 or (804) 367-4691
Fax: (804) 212-2174
Email: enfcomplaints@dhp.virginia.gov
Vermont
You understand that you have the right to receive a consult with a distant-site provider and will receive one upon request immediately or within a reasonable time after the results of the initial consult. You understand that receiving telehealth services via store-and-forward technologies by Jimini Health does not preclude you from receiving real-time telemedicine or face-to-face services with the distant provider at a future date. Vt. Stat. Ann. § 9361.
If you want to register a formal complaint about a physician, you should visit the medical board’s website, here:
http://www.healthvermont.gov/health-professionals-systems/board-medical-practice/file-complaint.
Board of Osteopathic Examiners can be found at: https://sos.vermont.gov/opr/complaints-conduct-discipline/#emr
Consumers who have inquiries or wish to obtain a form to register a complaint regarding a professional counselor may do so by calling the Office of Professional Regulation at (802) 828-1505, or by writing to the Director of the Office, Secretary of State’s Office, 89 Main Street, 3rd Floor, Montpelier, VT 05620-3402.
Washington
You understand the purposes of and resources available to you surrounding this treatment, including the right to refuse treatment, and your responsibility in choosing a provider and treatment that best suits your needs. RCW 18.19.060.
The information you share in psychotherapy is protected health information and is generally considered confidential by both Washington state law and federal regulations, with some limited exceptions (e.g., may be shared with another healthcare provider, required by subpoena). RCW 18.19.180.
Counselors practicing counseling for a fee must be credentialed with the department of health for the protection of the public health and safety. Credentialing of an individual with the department of health does not include a recognition of any practice standards, nor necessarily imply the effectiveness of any treatment. The purpose of the Counselor Credentialing Act, chapter 18.19 RCW, is to: (A) Provide protection for public health and safety; and (B) Empower the citizens of the state of Washington by providing a complaint process against those counselors who would commit acts of unprofessional conduct. Clients have the right to choose counselors who best suit their needs and purposes.
A copy of the acts of unprofessional conduct in RCW 18.130.180 can be found on the Washington State Legislature’s website at this address http://apps.leg.wa.gov/RCW/default.aspx?cite=18.130.180.
Here is the name, address, and contact telephone number within the department of health for complaints.
Washington State Department of Health Professions Quality Assurance
P.O. Box 47865 Olympia, WA 98504-7865
(360) 236-4700
Wyoming
Wyoming has implemented a privileged communication statute that states that, when involved in legal proceedings (civil, criminal or juvenile) clients retain the right to privacy, unless these specific circumstances exist: (a) abuse or harmful neglect of children, the elderly or disabled or incompetent individuals is known or reasonably suspected; (b) the validity of a will of a former client is contested; (c) information related to counseling is necessary to defend against a malpractice action brought by a client; (d) an immediate threat of physical violence against a readily identifiable victim is disclosed to the counselor; (e) in the context of civil commitment proceedings, where an immediate threat of self-inflicted harm is disclosed to the counselor; (f) the client alleges mental or emotional damages in civil litigation or his/her mental or emotional state becomes an issue in any court proceeding concerning child custody or visitation; (g) patient or client is examined pursuant to a court order; or (h) in the context of investigations and hearings brought by the client and conducted by the board, where violations of this act are at issue. Providers will adhere to the Code of Ethics of the National Association of Social Workers; American Counseling Association; American Association of Marriage and Family Therapy; or National Association of Alcoholism and Drug Abuse Counselors, whichever is applicable for the provider’s profession. Wyo. Stat. Ann. § 33-38-113.
Wyoming Mental Health Profession Licensing Board 2001 Capitol Ave, Room 105
Cheyenne, WY 82002
Tel: (307) 777-3628
Fax: (307) 777-3508
wyomhplb@wyo.gov