Healthcare Zoom Addendum

HEALTHCARE ZOOM ADDENDUM

This Zoom Addendum supplements the existing patient-provider agreement and documents the patient's informed consent to receive healthcare services via the Zoom videoconferencing platform (telehealth). It describes the nature of telehealth, the risks and benefits, patient responsibilities, privacy considerations, and the patient's authorization for telehealth encounters. The patient may withdraw consent at any time.

Patient Information

Emergency Contact

Insurance Information

Medical History (Relevant to Telehealth)

Telehealth (Zoom) Consent

I, , hereby consent to receive healthcare services via the Zoom videoconferencing platform. I understand that telehealth involves the real-time transmission of my health information, including video, audio, and medical data, and that the provider may conduct assessments, provide treatment recommendations, and prescribe medication as clinically appropriate.

I acknowledge the following specific considerations:

• Potential risks: interruptions, loss of data, unauthorized access despite reasonable safeguards, and limitations of remote assessment.
• Potential benefits: increased access to care, convenience, and reduced travel burden.
• Alternative options: in-person visits, telephone-only consultations, or referral to local providers when appropriate.

I understand that I have the right to withhold or withdraw consent to telehealth at any time without affecting my access to future care. Withdrawal of consent will not affect the validity of any telehealth services provided prior to withdrawal.

Technology, Privacy, and Patient Responsibilities

Patient must ensure appropriate technology and environment: a private, well-lit location; a secure internet connection; and a compatible device with camera and microphone. The patient agrees to notify the provider if interruptions or privacy concerns occur. The patient is responsible for the confidentiality of their device and for providing accurate contact information.

Privacy: While the provider will use reasonable safeguards to protect private health information in telehealth encounters, potential privacy risks exist. I acknowledge receipt of the practice's privacy policies and understand that authorized staff may access telehealth records as required for treatment and administration.

Recording and Session Documentation

I consent to the audio/video recording of the telehealth session: Yes No

If recorded, recordings will be maintained as part of the medical record for clinical, quality assurance, or legal purposes and only retained and accessed in accordance with applicable policies. If I do not consent to recording, I understand the session may still proceed without recording unless state law or the provider's clinical judgment requires otherwise.

Limitations, Emergencies, and Follow-Up

Telehealth is not appropriate for all conditions. If the provider believes an in-person evaluation or emergency care is necessary, the provider will direct appropriate next steps. In a medical emergency, call your local emergency services. For urgent issues arising during a telehealth session, please contact local emergency services before contacting the provider.

Billing and Insurance

Telehealth visits may be billed to insurance or patient as permitted by coverage. Charges for telehealth services will follow the provider's standard billing practices. I authorize the provider to bill my insurance and to release information necessary for billing.

Authorization and Acknowledgment

By signing below, I acknowledge that I have read and understand this Zoom Addendum; I have had the opportunity to ask questions and have received satisfactory answers; and I agree to participate in telehealth services under the terms set forth herein. I consent to the use of Zoom for telehealth encounters with my provider.

I acknowledge that I may revoke this authorization at any time in writing, except to the extent that action has already been taken in reliance on this authorization.

Sign Now