Healthcare eHealth Package

Healthcare eHealth Package

Patient Information

Patient Name:

Male Female Other/Prefer not to say

Emergency Contact

Insurance Information

Medical History

eHealth / Telemedicine Consent

I authorize the use of telemedicine, electronic health records, and secure electronic communications for my care. Telemedicine includes live audio and video communication, store-and-forward transmission, remote monitoring, and related electronic exchanges. I understand that telemedicine may be limited by equipment failures, connectivity interruptions, or other technical problems and may not be sufficient for all medical conditions.

By selecting the boxes below I acknowledge the stated items and consent to participate in eHealth services for diagnosis, treatment, consultation and follow-up as appropriate:

I consent to receive telemedicine services.
I consent to receive appointment reminders, test results, and clinical messages via secure electronic channels, email, and/or SMS.
I consent to the storage of my medical records in electronic health record systems maintained by the provider.
I acknowledge that transmission of data by electronic means carries a risk of interception and that the provider will take reasonable precautions to prevent unauthorized access.

Authorization to Release or Exchange Health Information

I authorize the provider to disclose my protected health information to the persons or entities listed below, for the purposes described. I understand that disclosures may include clinical notes, laboratory results, imaging, billing and insurance information as indicated.

Types of information to be released (check all that apply):

Entire medical record
Laboratory results
Radiology / imaging reports
Billing / claims information
Other (specify below)

I understand that I may revoke this authorization at any time by providing a written notice to the provider, except to the extent that action has already been taken in reliance on this authorization. Authorization does not permit re-disclosure by the recipient except as allowed by law.

HIPAA Privacy Acknowledgment

I acknowledge that I have been offered a copy of the provider's Notice of Privacy Practices explaining how my health information may be used and disclosed and how I can access this information. I understand my rights under applicable privacy laws and that the provider will use reasonable administrative, physical and technical safeguards to protect my electronic health information.

I acknowledge receipt of the privacy practices notice or decline to receive a copy at this time.

Payment and Assignment

I authorize the provider to submit claims to my insurance carrier and to release pertinent medical information required for payment. I assign benefits payable for services rendered to the provider. I understand that I remain financially responsible for any portion not covered by my insurer, including co-payments, deductibles and non-covered services.

I authorize assignment of insurance benefits to the provider.

Patient Rights and Withdrawal of Consent

I understand that I have the right to inspect and obtain copies of my health information, request amendments, and obtain an accounting of disclosures, subject to applicable law. I may withdraw my consent for telemedicine or the release of information at any time by submitting a written request, except where action has already been taken in reliance on this consent.

I acknowledge that I have read and understand my rights as described above.

Certifications and Patient Statement

By signing below, I certify that the information provided on this Healthcare eHealth Package is accurate to the best of my knowledge. I authorize the provider to deliver medical evaluation and treatment via in-person or telemedicine modalities as clinically indicated. I understand the risks, benefits and alternatives and consent to the uses and disclosures described in this document.

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