Healthcare Telehealth Release Form

Healthcare Telehealth Release Form

Patient Information

Patient Name:

Date of Birth:   Gender:

Emergency Contact

Insurance Information

Relevant Medical History

Telehealth Consent and Release

I, the undersigned patient or legal representative, authorize the use of telehealth for the provision of health care services. Telehealth includes synchronous audio and video communication, asynchronous transmission of medical information, and remote monitoring as necessary to provide medical evaluation, diagnosis, consultation, treatment and follow-up.

I understand the following material facts, risks, benefits and alternatives:

- Risks: Potential risks include but are not limited to technical failure, delays, loss of information, limited physical examination, and reduced ability to respond to emergencies via electronic means. Telehealth sessions may be recorded only with my prior explicit consent below.

- Benefits: Telehealth can increase access to care, reduce travel time, and allow continuity of care when in-person visits are impractical.

- Alternatives: Alternatives include in-person evaluation, delay of treatment until in-person services are available, or no treatment.

- Emergency Protocol: In the event of an emergency during a telehealth encounter, staff will follow established emergency procedures which may include directing me to seek in-person emergency care or contacting emergency services.

Authorizations (check all that apply)

I authorize the delivery of health care services via telehealth, including medical assessment, treatment planning and follow-up.

I consent to the use of two-way audio and video communications for telehealth encounters.

I consent to audio and/or video recording of telehealth sessions for clinical purposes (only if checked). I understand recordings will be maintained as part of the medical record unless otherwise specified.

I consent to transmission of still images, photos or written materials for diagnostic or treatment purposes.

I authorize exchange of relevant protected health information with other health care providers, pharmacies, or payers as necessary for my care via telehealth.

I consent to receive communications related to my care by telephone, text message, or unencrypted email, understanding the privacy risks of such methods.

Privacy, Confidentiality, and HIPAA

The same standards of confidentiality that apply to in-person care apply to telehealth. Reasonable technical and administrative safeguards will be used to protect privacy. I understand that despite safeguards, no transmission over electronic media can be guaranteed to be completely secure.

I acknowledge that I have been offered or provided a copy of the organization's privacy practices and understand my rights regarding protected health information in the context of telehealth services.

Limitations, Revocation and Expiration

I understand I may withdraw consent at any time by submitting a written revocation to the treating provider. Withdrawal will not affect actions already taken in reliance on this consent. This authorization is valid until the date specified below or until revoked in writing, whichever occurs first.

Interpreter / Accessibility Needs

Do you require an interpreter or special accommodations for telehealth visits?
Yes No

Patient Certification

By signing below I certify that I have read and understand this Telehealth Release Form, that my questions have been answered to my satisfaction, and that I consent to receive telehealth services as indicated above. I attest that the information I have provided on this form is true and accurate to the best of my knowledge.

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