Frequently Asked Questions about Teletherapy

Informed Consent

1. If you are scheduling a telehealth appointment & need to send informed consent prior to the appointment, you would have to use email (since I would not be seeing them face-to-face. Am I exposed by sending this email before I've gotten consent from the client to send the email?

No. The consent document does not have any patient identifiers on it. Make sure you have the correct e-mail address to send the consent to.

2. As part of my informed consent for teletherapy I require clients to give an address they will be located at.

This is a good practice.

3. So can you not EVER provide services over a phone call? For example, I have clients who've had car trouble or caught in traffic and called in.

You can have a session by phone if the client has consented in writing to that type of service.

HIPAA-Compliant Video/Text/Call

1. Is FaceTime a safe way to communicate with clients?

Only if you have a secure internet connection.

2. I’ve heard that Signal is a HIPAA-compliant means of texting.

It appears to be secure and therefore HIPAA compliant, but if you are considering using this platform, do your homework and have a detailed call with the company representative before signing up.

3. If one uses a cell phone for business and personal but treats every contact as business and confidential, what are the risks? (for a solo practitioner and no one else has access to any devices)

It is too easy to click the wrong contact for a text or phone call and get a friend instead of a client. Additionally, if your phone is hacked or stolen, you have now exposed yourself to multiple HIPAA breaches.

4. So, using a regular phone is not sufficiently secure? Are there secure phone systems you recommend?

There are phone systems that are secure, but we don’t make recommendations on specific products. It is important to check with companies offering that service.

5. Is there a list of HIPAA compliant data storage systems?

No.

6. Doesn’t HIPAA require separate forms for telehealth services?

It is never a bad idea to have a separate consent form for telehealth services. However, you need to check HIPAA and your state regulations regarding telehealth services.

7. Doesn’t the social worker also have to keep a breach log?

Yes

8. Is it okay to use unencrypted email for things such as setting up appointments and receiving insurance membership numbers?

Insurance numbers are considered protected health information. Confirming an appointment is alright if you have an agreement with the client to confirm (or cancel) appointments in this manner.

9. What about utilizing email for a follow up after a session? (e.g., a referral for another agency's support). Does client consent for utilizing email cover me in terms of the risk of others reading this information?

If someone else got the e-mail, it could be considered a HIPAA breach since information about other providers could be interpreted as protected health information.

10. Is Skype secure for telemedicine?

Only if the internet connection is secure.

11. Is there a site where acts or standards beyond HIPAA are listed which we can review?

No, unfortunately not.

12. What are the limitations to doing clinical supervision via a confidential video services? i.e. BlueJeans, Zoom, etc.

You should contact your state licensing board for clarification and direction.

Licensing, Practicing Across States, Outside the Country

1. Given these new national ethics standards, are state NASW chapters working on developing a way to offer transitional status to a provider whose client has moved to another state, so there can be an orderly transfer of services - much like insurance companies offer 2-3 transitional sessions when the client has a new policy where you aren't a preferred provider?

The provider would need to have the transfer sessions prior to the client leaving the state. It is inappropriate to continue to treat a client after the client has left the state unless you are licensed in that state. Hopefully, you have enough time with the client prior to their departure to have at least one transition session

2. Regarding out of state treatment, I had a request for service from a man in the next state, a few miles from my state- to provide telemedicine. My state's Board of Social Work representative said it was no problem to do this. This disputes what you're saying. Comment? My state of licensure is Maryland. This client, when told this, suggested he could drive a few miles and sit in his car, then be in Maryland.

If the Licensing Board representative didn’t have a problem with this, it may be alright in your state, especially if the client wants to drive to Maryland.

3. What is involved in getting licensed in other states?

Each state’s requirements are different, and some states might offer reciprocity with your current state. Contact the state licensing board for more information.

4. Do many states have reciprocity?

You need to reach out to the state licensing board for information specific to the states in which you are interested in being licensed. However, be aware that license reciprocity means that a state will honor your credentials from another state when you apply and pay for a practice license. This is often confused with the term license portability, which means another state will honor your license from another state.

5. My understanding about current questions (of clients traveling to other states) is that you use the client's RESIDENCE. So if they travel to another state for vacation, I could still see them. Could you clarify if this is correct?

This is incorrect. You use the client’s current location, or where the phone is located. You cannot practice across state lines.

6. With regard to the example of the client that relocated and practicing without a license: If the social worker leaves the state (maybe on vacation?) but is licensed in the same state as the client is located, is this acceptable?

For example, if you have a social worker who is licensed in Georgia and Florida and is in Florida on vacation, that social worker could treat a client who is physically in Florida.

7. There are a number of mental health professionals providing services across state lines, and they have licenses in multiple states. If you provide services to a client in another state and you're licensed in that state, do you have to report your income in the other state?

You should consult a business law attorney or a tax professional to get the answer to this one.

8. What about treating clients who are traveling internationally?

With clients who either live or are traveling internationally, do your best to find resources for your clients where they are traveling, but do not treat them yourself while they are out of the country.

9. What if I as the clinician am traveling on vacation outside the state I’m licensed in. A client calls me while I am on vacation and needs clinical support. Can I give it to them if they are in the state I see them and am licensed in even though I am out of state?

No. Refer them to someone who is in your state and let them handle the emergency. It would be a good idea to have someone for the client to reach out to if you are going to be out of state for an extended period of time.

10. Some states give emergency or short term provisional licenses.

Each state is different, and probably not something that can be granted through a phone call. Don’t assume this is something that can happen – better to ask in advance.

11. Doesn't our code say we have to be licensed in both locations?

The NASW Code of Ethics does not address licensing. That is the responsibility of the state licensing boards.

12. So if my client goes on vacation out-of-state and feels they have an emergency and needs to talk to me to get settled, I cannot talk with her over the phone because she is temporarily in another state?

If you have a client in crisis, you can talk with her but you should also be referring her to someone in the state where she is vacationing.

13. Also, if I am on vacation can I provide services to my client back home in their emergency or am I providing services in a state where I am not licensed?

Correct.

14. Is there a process for obtaining licensure in multiple states or must one do so for each state?

You must apply for a license in each state. However, if you have your LCSW, some states will only require proof of your credentials and an application (with the licensing fee). Each state is different.

15. Can NASW work on having all states recognize LCSW in one state to be recognized in another automatically?

States differ in the types and levels of licensure their legislature has passed into law. The Association of Social Work Boards (ASWB) has information on state licensing on their website.

16. Since you cannot know where someone is at the time of service (i.e. cell phone); it appears you can never provide services online or cell. True?

You have to trust that your client is telling you the truth when you ask where he or she is located. Make sure to document the conversation. If later they claim you practiced outside your state, you can state that the client stated he or she was in the state when you spoke. It is not a solid defense, and this will wind up causing you a lot of time and heartache. It is best to have a conversation with the client at the beginning of your care and explain the situation.

Access to Records

1. If providing electronic service to a client who wants access to their records, must that be provided in the electronic format, or can the clinician print what is appropriate and send it to the client?

We are not certain what is meant by “electronic service,” but it is certainly appropriate to print an electronic medical record and provide the paper copy to the client.

2. Are there any mandates for all records to become electronic?

Electronic medical record requirements are generally limited to large hospitals or physician clinics. However, check HIPAA and your state regulations to be certain.

Teletherapy: The New Norm in Client Care

1. What are the many ways non-traditional communication can be described?

A few different references exist for services to individual clients outside of an in-person meeting. These can include, but are not limited to, tele-practice, teletherapy, tele-mental health, telehealth, online counseling, telephone counseling, videoconferencing, self-guided web-based interventions, electronic networks, mobile apps, automated tutorials, e-mail, text messages, and a host of other options.

2. I have always seen my clients in person prior to the pandemic. I am aware that many of my colleagues are using technology to provide telehealth services for their clients for several years. How do I begin online sessions? What are the guidelines I need to be aware of to assure ethical practice?

Please Pause and Review as things are changing daily with client communication regulation as social work and mental health regulation still resides with state boards of social work/mental health providers. It is extremely important to read and understand the laws in your state before contacting your clients. All state regulating boards have these regulations on their websites, so please read them and be ready to take notes, as some states have continuing education completion as an advance requirement.

Most, but not all, states have provisions to allow certain alternative communication efforts; however, the law requires the licensee to confirm adherence to the law in advance of providing services. It is critically important to understand that if a state completely outlaws the practice, DO NOT PROCEED, as the outcomes can be very destructive to licensure.

Important review source is the NASW/ASWB/CSWA Technology Standards, Section 2.02 Services Requiring Licensure or Other Forms of Accreditation (page 12) and Section 2.03 Laws that Govern Provision of Social Work Services (page 14).

3. Can I just choose any form of electronic communication available, especially free options?

No. First, review the guidelines outlined in state regulation, with an important focus on platforms that are bound to secure communication and are HIPAA compliant. Some platforms will offer and guarantee a secure venue but will likely have a fee for this option.

In addition, as the NASW/ASWB/CSWA Technology Standards point out steps to protect confidentiality on page 24, “precautions to protect confidentiality depend on the type of technology being used, and may include:

using passwords, firewalls, encryption, and antivirus software
using electronic service providers that rely on standards of security for data that are transmitted and stored
ensuring a private setting when using their electronic devices”

4. Can I provide tele mental health services to ALL of my clients?

Especially given the current pandemic restrictions, be aware that teletherapy is not always one size fits all. Over time, you know your clients well and the best way to connect with them. Assess each client individually to determine the best available communication resource for them. Clients at risk for self-harm or injurious behavior and those who may be cognitively impaired may not be good candidates for teletherapy. Take careful time and effort to document your decision-making process in client records, assuring adherence to confidentiality, HIPAA regulations, professional ethics, and other relevant regulations. Review the Technology Standards to explore this further.

5. Once I have cleared other efforts to connect remotely with my clients, should I consider steps to make things clear to them about this change in communication?

It is critically important to establish expectations for your clients through an informed consent document that is reviewed and signed by your client. Your state may have some requirements or items to include in the informed consent document relating to the telehealth service. It is best to either review and uses the Telehealth Informed Consent document from NASWASI or create a document and review it with a local attorney. An attorney can ensure the inclusion of your state laws.

6. My client will only see me in-person and refuses any other communication option, what should I do?

The SW professional should politely explain that it is important to comply with stated local mandates for social distancing. The social worker should explain how the Telehealth process will work, offer a trial appointment or make an appointment for a later date when social distance restrictions are relaxed. Always document your conversation with your clients.

7. What are the best resources to consider further?

Review the professional standards for the provision of tele-practice services found in The NASW, ASWB, CSWE &CSWA Standards for Technology in Social Work Practice and the NASW Code of Ethics.

Also, check out the Technology in Social Work Practice Webinar

This risk management webinar is an excellent resource if you are exploring new communication options. Technology in Social Work Practice, offered by the National Association of Social Workers, is CEU eligible and a great tool for anyone using technology to deliver services. Visit the Social Work Online CE Institute online. *This course is CEU eligible and would have a corresponding fee.

Miscellaneous

1. I am trying to put together a professional will and want to know how long I would need to ask my executor to be able to provide records to clients. Would it be for 7 years?

Review the professional standards for the provision of tele-practice services found in The NASW, ASWB, CSWE &CSWA Standards for Technology in Social Work Practice and the NASW Code of Ethics.

Also, check out the Technology in Social Work Practice Webinar

2. I work with deaf people using American Sign Language. I’m considering using telehealth, as I live in a very large, rural state. Many individuals have asked for this service but I’m not sure which training I need to take and how to start. I’m fluent in ASL.

Review the professional standards for the provision of tele-practice services found in The NASW, ASWB, CSWE &CSWA Standards for Technology in Social Work Practice and the NASW Code of Ethics.

Also, check out the Technology in Social Work Practice Webinar

3. Hospitals are not allowed to store any patient records in the cloud. How are social workers and private practices getting around this or are they not under the same confidentiality standards?

There have been problems with that type of storage because the providers sometimes go out of business and leave the provider with no access to their records. An external hard drive would be easier and safer.

4. What are the recommendations for how to erase/dispose of old electronic devices like laptops, desktops?

Take the machine to a company that specializes in wiping those drives.

5. Are social work clinicians required to keep electronic records as opposed to paper?

If a clinician is part of an agency that uses an EMR or EHR, then they must use the electronic record. Consult a local attorney if you have any specific questions.

6. Aren't all telephone calls through a cell phone at risk for interception? Or a voicemail overheard? Should we require people to use landlines? So maybe I need to write in the informed consent that I can't take responsibility for info they allow someone else to read, hear or read.

Unless you are using a secure phone line, any call is susceptible to hacking. You can try to require a landline, but in this age of cell phones, more people have cell phones than landlines. It could be an impossible requirement.

7. There is an app you can buy that allows for a separate phone number that rings on your personal phone. Is that adequate separation per the standard?

Yes.

8. Does the use of technology create challenges to obtain fees?

No.

9. So the standard confidentiality notice on the e-mail isn't good enough?

If there is a question, consult an attorney.

10. What about those of us in private practice who still keep paper records? Any guidance related to this in this new landscape?

Keep your paper records secure as you always do, continue to document as you always have. Understand that at some point you may have to switch to electronic records.

11. It would be good to define technology services. People think if they are not doing distance therapy they are not using technology, yet they are doing email, texting, electronic record storage, billing, etc.

Very good point! Anything involving electronics is technology.

12. Can you reinforce to attendees that even if the client is ok, we as the social workers need to do everything possible to protect confidentiality.

Very good point!

13. I assist a psychotherapist with her billing. What kinds of safeguards do I the assistant and the psychotherapist need to have in place? Business Associates Agreement?

At a minimum, a Business Associate Agreement is a must. Discussions with the psychotherapist about how to transmit information for billing purposes in a secure manner are also a must. The security of the information should be the most important thing. If you can, you should also get an Errors & Omissions liability insurance policy.

14. What if you get info about a client that is not yours from a health care provider?

Inform the health care provider about the error and then forget the information, exactly as you would expect if you gave another provider information they should not have.

15. You mentioned that a client may not be able to see a therapist due to inability to physically attend a session. What if the client can physically see a therapist face to face and has done so in the past, but due to a request they would like to use technology for future sessions?

Circumstances might require that a therapist offer technology for sessions – for example, if the therapist has an office on the second floor of an older building and the client is disabled and unable to use the stairs, technology might be the only way they can work together. If you have concerns about providing services to this client through technology, you could have a conversation with the client to set parameters around the therapy and the expectations for both sides.

16. If I inform my client that Facetime is not secure and they still desire to talk over Facetime, can I provide the service?

Have the client sign a consent acknowledging that they are aware that a Facetime connection is not secure and the information shared in sessions could be accessible.

17. Is telehealth covered by Medicare and other major health insurance companies?

You would need to consult with each carrier to find out if they cover telehealth services.

18. Is it appropriate to see a client privately if they were a previous online client?

Yes.

19. I received a deposition notice from a previous client and my former school system. Does the school have to give me access to my electronic records stored on their record-keeping systems?

The school’s attorney should be willing to work with you to access the records to allow your review prior to your deposition.

20. What do you do if you work for an organization and have very limited control over maintaining many standards discussed? An example would be not being able to control who has access to information within the agency.

If there are policies or standards in the agency that you believe are compromising either your ethics or license, you should discuss the concerns with the management of the agency. If not, you need to find a new agency.

21. What were the names of the Acts (laws)?

Health Insurance Portability and Accountability Act of 1996 (P.L. 104-19)
Protection of Alcohol and Drug Abuse Patient Records (42 CFR Part 2)
Family Educational Rights and Privacy Act of 1974 (P.L. 93-380, S513)
Section 215 of the USA Patriot Act of 2001 (P.L. 107-156)

22. Does NASW offer cyber liability insurance?

Yes, we offer six of the best and most affordable plans in the industry for individual practitioners. (For more info)

23. I password protect my phone, is that enough separation of personal and professional?

The best separation would be separate phones.

24. A college mental health counselor's professional e-mail is a Gmail account. This therapist has other personal Gmail accounts. On her cell phone the Gmail icon can be clicked and there is access to all of her Gmail accounts without the need to first put in a password. Should this therapist put her e-mail on "vacation/away" mode at the end of each work day and also include a message that states that work e-mail is Gmail and there are risks with e-mailing?

First, clicking one icon to get to all e-mail accounts without a password is very risky. Anyone who picks up the phone could get to confidential e-mails. That is a higher concern. An out of office message at the end of the day is not necessary.

25. Can a therapist e-mail links to helpful resources to clients? Like links to online guided relaxation app. if the client has already said it is okay to communicate about resources and appointments via e-mail?

If a therapist is going to e-mail anything to a client, there should be consent in the file authorizing that type of communication. After that, there is no problem e-mailing links to resources.

26. What advice or comments would you have about the organizations that are out there that do "text" therapy?

Make sure you know who the person is on the other end. If you only communicate by text message, how do you know who you are talking to?

27. To clarify: if a personal cellphone is used with a line dedicated for patients' ability to text provider, it is ok to use and only should be used for appointments questions?

The line must be secure.

28. What happens when you send info about a breach to Health & Human Services?

The breach is investigated by HHS. We don’t know the specifics of their investigation.

29. Where can one learn about how to be sure that one is using technology for client communication through email, text messaging, and appointment setting software that is HIPAA compliant?

Speak to internet providers and software providers. You’ll need to do homework and ask a lot of questions.

30. If an emergency do you need releases of information?

It is better to have them in advance, but in a matter of life and death, you can move without one. If you have a good faith reason for your actions, you should be okay.

31. Is there a specific video technology platform that you would recommend to utilize for telehealth services?

The wireless connection is more important than the platform. Both should be secure, but the connection is secure is more important.

32. Since you can't send emails without encryption, is direct phone contact the only HIPAA compliant way to communicate with clients? How does one begin to encrypt emails?

The only sure HIPAA compliant way to communicate with clients is by face to face communication. You need to have encryption software. Check with your e-mail provider.

33. If you have a specific landline number for your private practice that doesn't allow texts, how do you forward that number to a private personal cell that allows texts?

Check with your phone provider.

34. Can you have phone sessions on a regular office line?

If it is a secure line, yes.

35. If client is a child and parents are in middle of custody dispute (unhealthy dynamics with father are ever present and child does not want father to have her records), can the father have copies of records?

State laws vary. You should check with an attorney in your state.

36. Are all insurance panels accepting sessions billed via technology? Does that need to be documented other than on billing?

It is individual to each insurance panel. Check with the panel to be sure.

37. When is it appropriate to use texts with clients?

Never, unless you have an encrypted texting service.

38. HHS Notification for a breach? Never heard of this! Please provide web link.

https://www.hhs.gov/hipaa/for-professionals/breach-notification/breach-reporting/index.html

39. Are phone sessions considered confidential?

Only if the phone line is confidential.

40. How do you secure a folder on your computer with client information?

Check with an IT expert on that.

41. What's your sense of how health insurance is covering teletherapy? With BCBSIL is seems that they will now only cover treatment provided by MDLive providers.

Each provider is different. You need to check with the provider to be sure of what they will or will not cover.

42. When doing a video conference meeting with someone who may not be local and is homebound; how do we do informed consent?

You could send the form by mail and have it returned prior to your meeting.

43. What if the agreed upon phone session begins and the provider realizes the client is driving?

Set expectations prior to the session – that the client is not driving and is in a safe location. Try to re-schedule if you realize the client is driving.

44. Are there simplified versions of complicated documents, like HIPAA or informed consent forms? It should be possible to give clients documents they actually understand, especially if they have cognitive challenges or developmental disabilities.

Consent forms and all initial documentation should be at around a 5th-grade reading level, in the language the client can understand. You can re-write the forms to make sure they are understandable.

45. How do we deal with liability & damage control, when the web host fails to protect the client's confidentiality?

Do your homework in advance. Before you sign up with a web hosting service, find out what to do if there is a confidentiality breach. If a breach occurs, follow your process by disclosing to the client(s) affected and report the breach through the HHS website.

46. If the wrong person accesses the client's email, they can follow instructions to open the encrypted message. Are we liable, if the client gives their secret password to someone else?

No.