Healthcare Web Consent Form

Healthcare Web Consent Form

Patient Information

Patient Name:

Male Female Other Prefer not to disclose

Emergency Contact

Insurance Information

Medical History

Web and Telehealth Consent

I authorize my healthcare provider and their authorized staff to communicate with me using web-based platforms, video conferencing, telephone, secure messaging, email, and text messaging as part of my care. I understand that electronic communications may involve risks including interruptions, unauthorized access, technical failure, and delays.

By checking the boxes below I give specific consent to the following methods of electronic communication (initial each method to indicate consent):

I consent to live video telehealth visits (video conferencing). I consent to audio-only telehealth visits (telephone/audio calls). I consent to secure patient portal messaging. I consent to routine communications by email (non-urgent). I consent to SMS/text notifications and reminders. I consent to audio/video recording of sessions for clinical documentation and quality assurance.

I understand that some communications are not fully secure and that the provider will make reasonable efforts to protect my information consistent with applicable privacy laws. I further understand that I may decline any method of communication and may revoke consent at any time by providing written notice.

HIPAA Acknowledgment and Authorizations

I acknowledge that I have received or had the opportunity to receive the provider's Notice of Privacy Practices describing how my protected health information may be used and disclosed. I authorize my provider to use and disclose my health information as necessary to provide telehealth services, to bill and collect payment, and to coordinate care.

I authorize the release of medical information to the following person(s) for the purpose of scheduling, communications, or treatment coordination. If none, leave blank.

Conditions, Risks, and Patient Responsibilities

I understand that telehealth appointments may not be appropriate for all medical conditions and that the provider may determine at any time that an in-person visit is necessary. I accept responsibility for maintaining appropriate technology, internet access, and a private environment during telehealth sessions. I will inform the provider of any change to my contact information.

I understand that the provider will attempt to notify me of technical problems and reschedule if necessary. I agree that the provider is not responsible for breaches of confidentiality caused by my failure to use secure devices or for actions by third parties outside the provider's control.

Revocation and Refusal

I understand that I may refuse or revoke this consent at any time by providing written notice to the provider. Revocation will not affect actions already taken in reliance on this consent prior to receipt of the revocation.

Patient Certification

I certify that I have read and understand the information in this Healthcare Web Consent Form. I have had the opportunity to ask questions and those questions have been answered to my satisfaction. I consent to the use of the electronic communication methods I selected above for my care.

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