Healthcare Online Program

HEALTHCARE ONLINE PROGRAM ENROLLMENT & CONSENT

Program Name:    Participant ID (if assigned):

Patient Information

Insurance Information

Medical History

Program Participation & Telehealth Consent

By enrolling in the Healthcare Online Program (the Program), I consent to participate in clinical, educational, and monitoring services delivered by secure electronic means. I understand the Program includes synchronous and asynchronous interactions, assigned modules, remote monitoring, messaging with care team members, and possible use of integrated third‑party platforms.

I acknowledge that I have been informed of the inherent risks of electronic communications, including but not limited to: interruption, unauthorized access, technical failure, and the potential for incomplete transmission of information. I accept these risks and agree to follow technical and privacy instructions provided by the Program.

Consent to Telehealth Services: I voluntarily consent to receive telehealth and online services as part of the Program.

Consent to Electronic Messaging and Reminders: I consent to receive appointment reminders, program notifications, and non‑urgent communications via email, SMS, or platform messaging.

Consent to Recording: I consent to audio and/or video recording of telehealth sessions when required for clinical documentation or program quality assurance, subject to confidentiality protections described below.

Privacy, Data Use, and HIPAA Authorization

I acknowledge that information created or transmitted in connection with the Program is part of my medical record and will be used and disclosed for treatment, payment, and health care operations. I understand that my personal health information may be stored and transmitted electronically and that reasonable safeguards are employed to protect confidentiality.

Authorization to Use and Disclose Protected Health Information: I authorize the Program and its affiliated providers to use and disclose my protected health information as necessary to provide services, coordinate care, consult with other health care professionals, bill payors, and comply with legal requirements. This authorization includes disclosure to contracted service providers and technology vendors to the extent necessary for program operations.

I understand that I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance upon it. Revocation must be submitted to the Program in writing and will not affect disclosures made prior to receipt of revocation.

Risks, Benefits, and Alternatives

Benefits may include increased access to care, convenience, and enhanced monitoring. Alternatives include in-person care or declining participation. Risks include limits to physical examination, potential delays due to technical issues, and privacy limitations. I acknowledge that my provider has discussed these matters with me to my satisfaction.

I understand I may withdraw consent and discontinue participation at any time without penalty to my continued access to other health services.

Emergency Procedures

The Program is not intended for emergency care. If I am experiencing a life‑threatening emergency I will call emergency services immediately. I consent to the Program contacting emergency services and/or the emergency contact listed above if the care team determines there is a risk of harm to myself or others.

I acknowledge that I have provided the Program with an emergency contact and that I will keep that information current.

Emergency Contact Confirmation: I confirm the emergency contact provided above is accurate and may be contacted in an emergency.

Fees, Billing, and Payment Authorization

I acknowledge that I am responsible for payment of fees for services not covered by insurance. I authorize the Program to submit claims to my insurance and, when appropriate, to accept assignment of benefits. I remain responsible for copayments, deductibles, and charges denied by my insurer.

Assignment of Benefits: I authorize payment of insurance benefits to the Program for services provided.

Release and Acknowledgments

I acknowledge that no guarantees have been made to me regarding outcomes. To the fullest extent permitted by law, I release the Program and its personnel from liability for claims arising solely from telehealth technical failure or delayed transmission, provided reasonable safeguards and professional standards were followed.

I understand the Program's policies regarding attendance, cancellations, and program removal for non‑compliance and agree to abide by those policies.

I have read and understand this Enrollment & Consent form. I have had the opportunity to ask questions and have received satisfactory answers. By signing below I certify that the information I have provided is accurate and that I consent to participate in the Healthcare Online Program under the terms set forth herein.

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