Healthcare Remote Services Authorization

HEALTHCARE REMOTE SERVICES AUTHORIZATION

Patient Information

Patient Name:

Date of Birth:    Gender:

Insurance Information

Medical History (Relevant)

Remote Services Description and Authorization

Provider/Practice Name:

Purpose of Remote Services:

I hereby authorize the provider identified above to provide health care services remotely using telehealth technologies and to electronically transmit and receive my protected health information as necessary to provide care, billing, and treatment coordination. This authorization specifically includes consultation, diagnosis, treatment, and the exchange of clinical information with other health care professionals involved in my care.

Video conferencing    Audio-only (telephone)    Store-and-forward (asynchronous)    Secure messaging / email    Text messaging

Risks, Benefits and Alternatives

Benefits: Remote services may allow greater access to care, convenience, and continuity of treatment. The provider may be able to evaluate, diagnose, and treat conditions remotely as appropriate.

Risks and Limitations: I understand telehealth has limitations including but not limited to: potential technology failures, intermittent service interruptions, reduced ability to perform physical examinations, limits to privacy and confidentiality despite security efforts, and possible delays in diagnosis or treatment. In some cases an in-person visit may be recommended and I consent to be referred for in-person services if clinically necessary.

Confidentiality and Electronic Transmission

I acknowledge that the provider will take reasonable steps to protect the confidentiality of my information during transmission and storage. I understand that complete confidentiality cannot be guaranteed and that exceptions to confidentiality include mandatory reporting of abuse or neglect, imminent risk of harm to self or others, court orders, and other disclosures required by law.

I authorize electronic transmission of my health information to other health care providers, health insurers, billing agents, and other parties as necessary for treatment, payment, or health care operations unless otherwise restricted below.

Do not disclose electronic clinical notes or telehealth session recordings to third parties:

Recording of Sessions

I consent to recording of telehealth sessions: Yes    No

If recorded, recordings will be stored, used, and disclosed only in accordance with applicable law and with the policies of the provider unless I specifically request additional restrictions in writing.

Technical Requirements and Patient Responsibilities

I confirm I have a device with camera and microphone (if required) and access to internet or telephone service adequate to engage in remote care. Device description:

I agree to be in a private location for sessions, to maintain up-to-date contact information, and to notify the provider promptly of any technical difficulties.

Duration, Revocation and Expiration

This authorization is effective on the date signed and shall remain in effect until: or until revoked in writing by the patient. Revocation will not apply to actions already taken in reliance on this authorization.

HIPAA / Privacy Acknowledgment

I acknowledge that I have been offered and/or received the provider's Notice of Privacy Practices describing how my protected health information may be used and disclosed. I understand my rights under applicable privacy laws.

I acknowledge receipt of the Notice of Privacy Practices.

Additional Authorizations

I authorize the provider to communicate with the following persons regarding my telehealth care and appointments (enter names and relationship):

Patient Certification

By signing below, I certify that I have read and understand this Authorization for Remote Services. I have had the opportunity to ask questions and have had those questions answered to my satisfaction. I understand that my participation is voluntary and that I may withdraw this authorization at any time in writing, except to the extent that the provider has already acted in reliance on it.

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