Administrative — Telehealth Informed Consent

TELEHEALTH INFORMED CONSENT Patient Name: [Patient Name] Date: [Date] Introduction

Telehealth involves the use of electronic communications (video/audio) to enable health care providers at different locations to share individual patient medical information for the purpose of improving patient care.

I understand and agree to the following:

1. Nature of Telehealth: The consultation will occur via interactive video/audio technology. I will not be in the same room as the provider.
2. Limitations:
* I understand that a physical exam is limited, which may affect the provider's ability to diagnose certain conditions.
* If the provider determines my condition requires a physical exam or is an emergency, I may be directed to an in-person clinic or ER.
3. Technology Risks:
* There are potential risks including interruptions, unauthorized access, and technical difficulties.
* If the connection is lost, the provider will attempt to contact me at: [Backup Phone Number].
4. Privacy:
* The laws that protect the privacy of my medical information (HIPAA) also apply to telehealth.
* I agree to be in a private, quiet location during the visit to ensure confidentiality on my end.
5. Billing:
* I understand that telehealth visits are billable services and I may be responsible for co-pays or deductibles, just like an in-person visit.

Consent

I verify that I have read and understand this form. I authorize [Provider/Practice Name] to provide services via telehealth.

Signature: __________________________ Date: [Date]

[Patient Name]