Healthcare Telehealth App

HEALTHCARE TELEHEALTH APPLICATION

Patient Information

Date of birth:    Gender:

Emergency Contact Phone:

Insurance Information

Medical History

Are you pregnant or breastfeeding?   Yes   No

Do you have any mental health conditions relevant to care?   Yes   No

Telehealth Services Requested

Technology & Patient Responsibilities

Device used:    Internet connection:

Patient agrees to ensure adequate privacy and minimize interruptions during telehealth sessions and to disclose current location at the time of each session: Agree

Risks, Limitations, and Alternatives

I understand that telehealth has limitations including but not limited to: potential technological failures, inability to perform a complete physical examination, reduced ability to obtain vital signs, and possible delays in evaluation. I acknowledge that my clinician may determine that in-person evaluation or referral to emergency care is necessary.

In the event of an emergency during a telehealth visit I will be responsible for contacting local emergency services. I understand clinicians will provide instructions for urgent conditions but may be limited by remote assessment.

Privacy, Security, and HIPAA Acknowledgment

I acknowledge that telehealth transmissions may be subject to interception despite reasonable safeguards. The provider will use systems designed to protect privacy in accordance with applicable law; however, absolute confidentiality cannot be guaranteed. By signing below I acknowledge receipt of the privacy practices relevant to telehealth.

Acknowledgement of Privacy Practices: I acknowledge I have received or been offered the provider's privacy practices and understand how my identifiable health information may be used in telehealth encounters.

Consent to Electronic Communications & Recording

I consent to receive telehealth services via electronic communications and authorize the provider to communicate appointment information, clinical notes, prescriptions, and test results electronically where permitted. I understand that standard text messaging and email are not fully secure and accept that risk.

Consent to audio/video recording for clinical or quality purposes:   Yes   No

Authorization to Release and Receive Records

I authorize the release and exchange of my protected health information as reasonably necessary to deliver telehealth services, to coordinate care, and for billing purposes. This authorization includes transmission of relevant images, notes, and records to consulting clinicians as required for my care.

Revocation and Withdrawal

I understand I may revoke this telehealth consent at any time by written notice to the provider, except to the extent action has already been taken based on this consent. Revocation will not affect disclosures made in reliance on this authorization prior to receipt of the revocation.

Acknowledgment and Certification

By signing below I certify that I have read and understand this Telehealth Application and Consent. I attest that the information I have provided in this application is true and accurate to the best of my knowledge. I agree to participate in telehealth services under the terms described above.

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