Healthcare County Care Online Consent Form

Healthcare County Care Online Consent Form

Patient Information

Emergency Contact

Insurance Information

Medical History

Consent for Online/Telehealth Services

I, the undersigned, authorize Healthcare County Care and its authorized clinicians to provide medical care and clinical services via online video, audio, or other electronic communications. I understand that telehealth involves the transmission of my health information, images, and statements for diagnosis, treatment, consultation, and follow-up. By checking the box below I voluntarily consent to receive services by telehealth.

I consent to receive healthcare services through telehealth and to the electronic transmission of my medical information for the purpose of clinical care and coordination.

Risks, Benefits, and Alternatives

The benefits of telehealth may include increased access to care, convenience, and continuity of treatment. The risks include potential technology failures, limited physical examination capability, and possible breaches of confidentiality. Alternatives include in-person care and referral to other providers. I acknowledge that no guarantee has been made regarding the results of telehealth services.

I acknowledge that the risks, benefits, and alternatives to telehealth have been explained and I have had the opportunity to ask questions.

Technical Limitations and Confidentiality

I understand that telehealth communications may be disrupted by technology failures, and that Healthcare County Care will take reasonable steps to protect my privacy. However, the transmission of data over electronic systems carries inherent risks. I authorize the use of my chosen electronic communication methods for appointment invitations, reminders, and clinical information.

Preferred contact for telehealth appointment notices: . I consent to receive secure electronic communications related to care:

Recording and Use of Images

Telehealth sessions may be recorded only with explicit consent. Recordings, if any, will be maintained as part of the medical record and subject to privacy protections. Consent to recording is separate from consent to treatment.

I consent to audio/video recording of my telehealth sessions for treatment and record purposes.

Financial Responsibility

I am responsible for payment of services provided via telehealth. Insurance coverage for telehealth varies and I remain responsible for any co-payments, co-insurance, or charges not covered by insurance. I authorize release of information necessary to process claims and to obtain payment.

I acknowledge financial responsibility for telehealth services as described above.

Right to Withdraw and Expiration

I understand that I may revoke this consent at any time by providing written notice to Healthcare County Care. Revocation will not affect actions already taken in reliance on this consent. This authorization expires on: .

HIPAA / Privacy Acknowledgment

By signing this form I acknowledge that I have received or been offered a copy of Healthcare County Care's Notice of Privacy Practices and that I understand how my protected health information may be used or disclosed in the context of telehealth.

I acknowledge receipt of privacy practices and my rights under HIPAA.

Certification and Authorization

I certify that the information I have provided is true and complete to the best of my knowledge. I authorize Healthcare County Care to disclose protected health information to other health care providers, emergency services, and payors as necessary for treatment, payment, and health care operations related to the telehealth services. I understand that providing false information is subject to applicable penalties under law.

Patient Attestation

By signing below I attest that I have read and understand this consent form, that my questions have been answered, and that I voluntarily consent to telehealth services as described herein.

Sign Now