Healthcare Telehealth Addendum

Healthcare Telehealth Addendum

This Telehealth Addendum supplements and modifies the existing patient-provider relationship and authorizations for delivery of health care services through telecommunication technologies. Patient Name: Provider Name:

Patient Information

Insurance Information

Medical History (Relevant to Telehealth)

Scope of Telehealth Services

The Provider may deliver clinical evaluation, diagnosis, treatment, medication management, follow-up care, and counseling services using telecommunication technologies (audio, video, and/or secure messaging) as clinically appropriate and agreed upon. I understand that not all services are suitable for telehealth and that the Provider will determine whether telehealth is appropriate for my condition.

Risks, Benefits, and Alternatives

I understand the potential benefits of telehealth include increased access to care and convenience. I recognize the potential risks, including but not limited to: technology failure, degraded image or sound quality, delays, breaches of confidentiality despite reasonable safeguards, and limitations compared to in-person examination. Alternatives include in-person visits or deferral of care until an in-person visit is available.

Technology, Security, and Patient Responsibilities

The patient is responsible for providing a suitable environment for the telehealth visit, including a private location and necessary technology (device with camera/microphone, internet access). The patient agrees to follow instructions for connecting and testing equipment. The Provider will make reasonable efforts to protect the confidentiality of information transmitted during telehealth encounters in accordance with applicable privacy laws and professional standards.

Recording and Third-Party Platforms

Telehealth sessions may be recorded only if both the patient and Provider consent in writing. Third-party, non-public-facing communication platforms may be used when clinically appropriate. Use of such platforms may involve privacy risks; I consent to the use of third-party platforms when clinically necessary.

Confidentiality, HIPAA, and Privacy Acknowledgment

The Provider's privacy practices apply to telehealth services. I acknowledge that I have been offered access to the Provider's Notice of Privacy Practices and that protected health information transmitted during telehealth will be handled in accordance with applicable law. Absolute confidentiality cannot be guaranteed; however, the Provider will take reasonable steps to safeguard my information.

Emergency Procedures and Limitations

Telehealth is not appropriate for medical emergencies. If I am experiencing an emergency, I will call local emergency services or go to the nearest emergency facility. If during a telehealth session the Provider determines that an in-person evaluation or emergency services are necessary, the Provider will direct me to appropriate local resources.

Authorization, Revocation, and Expiration

I voluntarily authorize the Provider to deliver health care services via telehealth as described above. I understand that I may withdraw this authorization at any time by providing written notice to the Provider, except to the extent that the Provider has already acted in reliance on this authorization. This authorization will remain in effect until the earlier of: (1) written revocation, or (2) the following date:

Certification and Consent

By signing below, I certify that I have read and understand this Telehealth Addendum, I have had an opportunity to discuss the information above, my questions have been answered, and I voluntarily consent to receive healthcare services via telehealth from the Provider named above. I acknowledge the risks, benefits, and alternatives described herein and accept responsibility for providing accurate information and for my telehealth setup.

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