Healthcare Digital Health Agreement

HEALTHCARE DIGITAL HEALTH AGREEMENT

Parties and Effective Date

This Healthcare Digital Health Agreement (the "Agreement") is entered into by and between Provider Name: and Patient Name: . The effective date of this Agreement is .

Patient Information

Emergency & Insurance

Medical History (Relevant)

Scope of Digital Health Services

Patient authorizes Provider to deliver health care services and communications through digital platforms including, but not limited to, synchronous telehealth consultations, asynchronous messaging, remote physiologic monitoring, patient portals, and mobile applications (collectively, "Digital Health Services"). Provider will determine clinically appropriate modalities and may use third-party service providers to facilitate such services.

Consent to Electronic Communications and Data Use

Patient expressly consents to receive communications related to care and administration by the following means. Patient understands standard message rates may apply and that certain communications may be unencrypted.

I consent to receive telehealth services and related electronic health communications.

I consent to receive appointment reminders and care-related messages by SMS/text message at the phone number provided.

I consent to receive care-related messages by email at the address provided.

Collection, Use, and Disclosure of Digital Health Data

Patient authorizes Provider to collect, store, and use health-related data generated or transmitted by patient-owned or provided devices and applications for purposes of treatment, care coordination, quality improvement, billing, and as required by law. Provider may disclose such data to care team members and authorized third-party service providers for these purposes.

Patient understands that while Provider implements administrative, technical, and physical safeguards to protect electronic protected health information, no transmission or storage system is completely secure and breaches or unauthorized access may occur. Provider is not responsible for non-provider systems or patient device security.

Authorization to Share Records

Patient authorizes the release of digital health records and communications to named recipients as indicated below. This authorization is in addition to other legal authorizations for disclosure and applies to digital transmissions where applicable.

Risks, Limitations, and Patient Responsibilities

Patient acknowledges that Digital Health Services have limitations, including potential technical failures, delays, incomplete transmission of information, and risk of unauthorized access. Digital Health Services are not appropriate for emergency or life-threatening situations. In an emergency, Patient must call local emergency services.

Patient agrees to: (a) provide accurate and complete health information; (b) maintain and protect access credentials; (c) promptly notify Provider of changes in contact information or health status; and (d) follow Provider's instructions for device usage and troubleshooting.

Fees, Term, and Termination

Fees for Digital Health Services, if any, will be charged in accordance with Provider's fee schedule and applicable insurance coverage. Patient is responsible for applicable co-payments and balances. This Agreement remains effective until revoked in writing by Patient or terminated by Provider. Patient may withdraw consent by providing written notice to Provider; withdrawal does not affect disclosures made prior to revocation.

Authorization Expiration and Revocation

Unless earlier revoked in writing, this authorization expires on . Patient may revoke authorization at any time by written notice to Provider, subject to legal restrictions and the Provider's obligations to retain records.

Limits of Liability and Indemnification

To the fullest extent permitted by law, Provider's liability for claims arising out of or related to Digital Health Services is limited to direct damages and does not include consequential, incidental, special, or punitive damages. Patient agrees to indemnify and hold Provider harmless from claims arising from Patient's misuse of Digital Health Services or unauthorized disclosures resulting from Patient's failure to safeguard credentials.

Governing Law and Dispute Resolution

This Agreement is governed by the laws of the State of . Any dispute arising under this Agreement shall be resolved in the forums permitted by applicable law.

Privacy Practices Acknowledgment

Patient acknowledges receipt of Provider's Notice of Privacy Practices describing the uses and disclosures of protected health information and Patient's rights. Patient understands digital transmissions may involve the creation of electronic records that are part of the medical record.

I acknowledge receipt of the Provider's Notice of Privacy Practices.

Electronic Signature Consent

By signing below, Patient affirms that they have read and understand this Agreement, consent to the terms herein, and agree that the electronic signature is the same as a handwritten signature for the purposes of validity and enforceability.

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