Healthcare Telehealth Agreement

HEALTHCARE TELEHEALTH AGREEMENT

This Telehealth Agreement (the Agreement) documents the informed consent of the undersigned Patient to receive clinical services using telehealth technologies from Provider Name: and affiliated clinical staff. Patient Name: acknowledges and agrees to the terms set forth below.

PATIENT INFORMATION

EMERGENCY CONTACT

INSURANCE INFORMATION

MEDICAL HISTORY

TELEHEALTH SERVICES — DESCRIPTION AND PURPOSE

Telehealth services use electronic communications to enable Provider to consult, diagnose, treat, educate and monitor Patient remotely. The expected benefits include improved access to care and convenience. Alternatives include in-person visits or referral to an appropriate local provider.

RISKS, LIMITATIONS, AND TECHNICAL CONSIDERATIONS

Telehealth care may have limitations compared to in-person care. Potential risks include but are not limited to: incomplete assessment due to lack of physical examination, interruptions in communication, delays, or failures of technology, and privacy risks inherent in electronic transmission of health information. Provider will take reasonable steps to minimize these risks but cannot guarantee confidentiality or completeness of clinical information transmitted remotely.

PATIENT RESPONSIBILITIES

Patient agrees to: ensure a private, safe location for sessions; use recommended devices and network connections; provide accurate medical history; report all medications and adverse reactions; inform Provider of changes in condition; and follow Provider instructions. Patient is responsible for scheduling follow-up and arranging for emergency care if necessary.

CONFIDENTIALITY AND HIPAA ACKNOWLEDGMENT

Provider will protect the privacy of health information in accordance with applicable law and professional standards. Telehealth encounters may be documented in the medical record. By signing below, Patient acknowledges receipt of the Provider's privacy practices and consents to the electronic transmission of health information for treatment purposes.

I acknowledge receipt of the Provider's privacy practices and consent to electronic communications for treatment, appointment reminders, and billing as described above.

CONSENTS (CHECK ALL THAT APPLY)

I consent to synchronous audio and video telehealth encounters.
I consent to the audio/video recording of sessions for clinical documentation and quality purposes (if recording is planned, Provider will obtain specific notice prior to recording).
I consent to receiving appointment reminders, clinical messages, and test results via secure electronic messaging or standard electronic means, understanding that standard electronic messaging may carry privacy risks.
I authorize the Provider to issue prescriptions based on telehealth encounters as clinically appropriate.

EMERGENCY AND DUTY-TO-WARN

Telehealth is not appropriate for emergencies. If Patient is experiencing an emergency, Patient must contact emergency services or proceed to the nearest emergency facility. Provider may have a duty to warn or take action, including contacting emergency responders, if Patient poses a serious risk to self or others.

LIMITATION OF LIABILITY

Patient acknowledges that Provider cannot guarantee clinical results and that telecommunications failures may occur. To the fullest extent permitted by law, Patient releases Provider from liability for harms resulting from technology failure or interruptions, except for willful misconduct or gross negligence.

AUTHORIZATION PERIOD AND REVOCATION

This authorization to participate in telehealth services is effective upon signature below and will remain in effect until Authorization Expiration Date: unless revoked earlier in writing. Patient may revoke consent at any time by notifying Provider in writing; revocation will not affect actions already taken by Provider in reliance on this consent.

ACKNOWLEDGMENTS AND CERTIFICATIONS

By signing below, Patient certifies that: (1) they have read and understand this Telehealth Agreement; (2) they have had the opportunity to ask questions and have received satisfactory answers; (3) they consent to the use of telehealth as described; and (4) information provided above is true and accurate to the best of their knowledge.

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