Healthcare Technology Authorization Form

HEALTHCARE TECHNOLOGY AUTHORIZATION FORM

Patient Name:    Date of Birth:    Gender:

CONTACT & INSURANCE

INSURANCE

MEDICAL HISTORY (BRIEF)

TECHNOLOGY TO BE USED

Please indicate the technologies and services included in this authorization (check all that apply):

Telehealth video consultations
Remote patient monitoring (wearable or home device)
Patient portal / secure messaging
Mobile application for health data entry
SMS / email appointment reminders and notifications
Audio/video recording of telehealth visits for clinical record
Cloud storage or third-party technology vendor access

SCOPE OF AUTHORIZATION

I authorize the use and disclosure of my protected health information (PHI) as necessary for the technology functions checked above. Authorize access to:

Full medical record as needed for clinical care
Medication list and prescription data
Laboratory and diagnostic test results
Radiology and imaging reports
Appointment scheduling and reminders
Psychotherapy notes (I understand this requires specific consent)

RISKS, BENEFITS & LIMITATIONS

I understand that use of technology and electronic communications involves potential risks, including but not limited to unauthorized access, data breach, technical failure, or inadvertent disclosure of PHI. Benefits may include improved access to care, timely monitoring, and convenience. Technology is not a substitute for emergency care; in an emergency, I will call local emergency services.

I acknowledge that the health care provider and authorized vendors will take reasonable technical and administrative safeguards to protect information but cannot guarantee absolute security. I accept these risks and consent to the uses described herein.

DURATION, REVOCATION & FEES

Effective Date:    Expiration Date or Event:

I may revoke this authorization at any time by submitting a written revocation to my healthcare provider's records office. Revocation will not affect actions taken in reliance on this authorization prior to receipt of the revocation. I understand that some technology vendors may retain backups and archival records in accordance with their policies.

I understand I may be responsible for costs associated with replacement or loss of devices provided for monitoring, and that the provider is not responsible for third-party vendor practices beyond reasonable contractual protections.

ACKNOWLEDGMENTS & AUTHORIZATIONS

By signing below I acknowledge and authorize the following (check all that apply):

I have received or been offered the entity's Notice of Privacy Practices.
I consent to electronic communications, including SMS and email, as indicated above.
I consent to audio/video recording of telehealth sessions as selected above for clinical documentation.
I authorize sharing of data with named third-party vendors necessary to provide the technology service.

CERTIFICATION

I certify that I have read and understand this Healthcare Technology Authorization Form. I understand the scope and limits of this authorization, the possible risks and benefits, and my right to revoke this authorization in writing. My consent is voluntary and will remain in effect until the stated expiration date or my written revocation.

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