Healthcare Teleconsent Form

Healthcare Teleconsent Form

Patient Name:    Provider Name:

Clinic/Practice:    Appointment Date:

Patient Information

Female    Male    Other / Prefer not to say

Insurance Information

Medical History (Relevant to Telehealth Visit)

Telehealth Services Description

Telehealth means the delivery of health care services using interactive audio, video, or other electronic communications to enable diagnosis, consultation, treatment, education, and care management when the patient and provider are not in the same physical location. Telehealth visits may include discussion of symptoms, review of records and images, and medication management. I understand that telehealth is not a replacement for emergency care.

Telehealth Modality:
Synchronous interactive video    Audio-only telephone    Store-and-forward or asynchronous transmission    Remote monitoring of physiologic data

Risks, Benefits, and Alternatives

Benefits of telehealth may include improved access to care, convenience, and continuity of services. Risks include technical failure, incomplete examination due to remote format, limits on diagnosis accuracy, privacy breaches, and possible need for in-person follow-up. Alternatives include in-person visits, referral to local providers, or seeking emergency care as appropriate.

By checking the box below, I acknowledge that the provider has explained the risks, benefits, and alternatives and that I have had an opportunity to ask questions.

I acknowledge receipt of the explanation of risks, benefits, and alternatives.

Confidentiality and Privacy

Telehealth communications may be recorded in the medical record. Reasonable efforts will be made to protect confidentiality and secure electronic transmissions; however, confidentiality cannot be guaranteed. Information disclosed during telehealth visits is subject to medical record documentation and may be released as permitted by law.

I acknowledge that I have received or been offered the provider's privacy practices and understand how my protected health information may be used in the course of telehealth.

Recording and Photographs

I authorize or decline recording of the telehealth visit as follows. Recordings, images, or video shall be used only for treatment, care coordination, and administrative purposes unless additional written authorization is provided.

I consent to audio/video recording.    I do not consent to audio/video recording.

Technical Requirements and Patient Responsibilities

I understand I am responsible for ensuring a private, quiet location for the telehealth visit, a working device with camera and microphone (if applicable), and a reliable internet or phone connection. I agree to inform the provider if other persons are present and to maintain privacy during the visit.

I understand and agree to the patient responsibilities described above.

Emergency and Limitations

Telehealth is not appropriate for medical emergencies. If I am experiencing an emergency, I will call emergency services or go to the nearest emergency facility. If technical failure prevents completion of the telehealth visit, an alternative plan will be pursued, including rescheduling or referral to an in-person visit.

Voluntary Consent and Authorization

I hereby voluntarily consent to participate in telehealth services provided by the named provider. I authorize my provider to use telecommunication technology to deliver clinical care, and to document the visit in my medical record. I understand I may withdraw consent at any time by notifying the provider in writing; withdrawal will not affect any actions taken prior to receipt of the revocation.

I understand I may withdraw this authorization at any time by providing written notice.

Release and Liability

I release the provider and the clinic from liability for any inadvertent disclosure caused by technical failures or unauthorized access beyond the provider's control. I understand that clinical judgment may require conversion to an in-person visit or referral to another clinician, and I consent to such action if clinically indicated.

Acknowledgment and Certification

By signing below I certify that I have read and understand the information contained in this Teleconsent Form, that my questions have been answered to my satisfaction, and that I consent to receive care via telehealth under the terms described herein.

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