Healthcare Telehealth Consent Form

HEALTHCARE TELEHEALTH CONSENT FORM

Provider Information

Patient Information

Patient Name:    Date of Birth:    Gender:

Insurance Information

Medical History (Relevant to Telehealth Visit)

Telehealth Service Description and Consent

I hereby consent to the provision of telehealth services by the Provider identified above. Telehealth services include the exchange of medical information through audio, video, and/or digital communications used to provide and support healthcare, which may include diagnosis, treatment, follow-up and education. I understand that telehealth visits may occur from an off-site clinician using secure audiovisual technology.

I understand the nature of telehealth and acknowledge the following risks, which may include but are not limited to: incomplete transmission of information, technical failures, interruptions, unauthorized access to communications, limitations in physical examination, and potential need for in-person follow-up. I understand that the Provider may determine that telehealth is not appropriate and may recommend in-person care.

By checking the box below I provide specific consents and acknowledgements related to my telehealth visit.

I consent to receive health care services via telehealth from the Provider.

I consent to the audio and/or video recording of this telehealth session for clinical documentation and treatment purposes only. I understand recordings will be maintained in my medical record in accordance with applicable law.

I authorize the Provider to share telehealth information with other healthcare professionals involved in my care, as clinically appropriate.

I understand that I may withdraw consent for telehealth at any time by notifying the Provider. Withdrawal of consent will not affect any actions taken prior to the Provider's receipt of my written revocation.

Privacy and Confidentiality

Telehealth communications shall be conducted in a manner intended to protect my privacy and confidentiality. However, I understand that telehealth may involve the transmission of my health information over electronic systems and that there is a risk of interception despite reasonable safeguards. The Provider will use administrative, technical, and physical safeguards consistent with law to protect my health information.

I acknowledge receipt of the Provider's privacy practices and agree to the use and disclosure of my protected health information for purposes of treatment, payment and healthcare operations as necessary for the telehealth encounter.

Patient Responsibilities and Technical Requirements

I agree to: (1) provide accurate and complete medical and contact information; (2) ensure my physical location is private and safe during the telehealth visit; (3) use appropriate technology (camera, microphone, internet connection) and notify the Provider if I experience technical problems; and (4) follow pre-visit instructions provided by the Provider. I understand telehealth is not suitable for emergencies; I will call emergency services or go to the nearest emergency department if I am experiencing a medical emergency.

Authorization and Expiration

This authorization to participate in telehealth and to share the specified information remains effective until: , unless earlier revoked in writing.

I understand that revocation must be submitted in writing to the Provider and does not apply to information already released prior to receipt of the revocation.

Acknowledgment and Signature

By signing below, I certify that I have read and understand this Telehealth Consent Form, that my questions have been answered, and that I consent to receive telehealth services under the terms described above. If signing as a legal guardian or authorized representative, I certify that I have the authority to consent on behalf of the patient.

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