Healthcare Remote Consultation Agreement

HEALTHCARE REMOTE CONSULTATION AGREEMENT

This Remote Consultation Agreement (Agreement) sets forth the terms under which the health care Provider and the Patient will engage in a remote consultation using telecommunication technologies. Provider Name: and Patient Name: agree to the terms below. Consultation Date:

Patient Information

Male Female Other Prefer not to answer

Emergency Contact

Insurance Information

Medical History

Consultation Details and Technical Modality

Requested Session Date: Requested Time:

Modality (select all that apply):

Video (synchronous) Telephone (audio) Secure messaging / store-and-forward Other

Technical and Environment Requirements

To participate in a remote consultation, the Patient acknowledges the following minimum requirements:

I have access to a device with camera and microphone or telephone. I will use a stable internet connection or telephone service for the session. I will be in a private space during the consultation to protect confidentiality. I understand that technical failures may require rescheduling or conversion to telephone-only service.

Risks, Benefits and Limitations

The Patient acknowledges that remote consultations have benefits and risks. Benefits may include increased access to care, convenience, and continuity of treatment. Risks include, but are not limited to, potential interruption, unauthorized access, or technical failure, and the possibility that the Provider may not be able to fully assess clinical signs without an in-person examination. The Provider does not guarantee any specific outcome.

The Patient understands that if the Provider determines that a remote consultation is insufficient, the Provider may recommend an in-person evaluation or referral to an appropriate facility.

Consent to Telehealth Services and Recording

By checking the box below, the Patient provides informed consent to receive health care services via telehealth modalities described above.

I consent to participate in remote consultations as described in this Agreement. I consent to audio and/or video recording of the session if necessary for clinical documentation. I understand recordings will be treated as part of my medical record. I consent to the use of electronic communications (email, text) for scheduling and non-sensitive communications.

Fees, Billing and Cancellation

Services provided remotely will be billed in accordance with the Provider's policies. Insurance coverage for telehealth may vary. The Patient is responsible for any co-pay, co-insurance, or deductible amounts required by their plan.

Cancellation Policy: notice is required to avoid cancellation fees.

Emergency Protocol

Remote consultations are not appropriate for medical emergencies. If the Patient is experiencing a medical emergency, the Patient should seek immediate in-person emergency care or contact local emergency services. The Patient acknowledges understanding of this limitation and agrees to inform the Provider if the condition worsens or if there is imminent risk.

I understand that telehealth is not appropriate for emergencies and I will seek immediate care if necessary.

Privacy, Confidentiality and Authorization

The Provider will take reasonable measures to protect the privacy and security of telehealth transmissions in accordance with applicable privacy laws. However, the Patient acknowledges that there are inherent risks in electronic communication and consents to the use of telehealth as described. The Patient authorizes the Provider to share relevant health information with other health care professionals involved in direct care or as required for treatment, payment, or health care operations.

I acknowledge I have been informed of the Provider's privacy practices and understand how my health information will be used in telehealth.

Authorization Period and Revocation

This authorization for telehealth services will remain in effect until: unless revoked earlier in writing by the Patient. The Patient may revoke consent at any time, except to the extent that actions have already been taken in reliance on this Agreement.

Patient Statements and Certifications

By signing below, the Patient certifies that the information provided in this Agreement is true and complete to the best of the Patient's knowledge, that the Patient has had the opportunity to ask questions, that such questions were answered to the Patient's satisfaction, and that the Patient voluntarily consents to receive remote consultations under the terms set forth above.

I have read and understand this Agreement and consent to telehealth services as described.

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