Telehealth Consent Form

  1. I understand that my health care provider wishes me to engage in a telehealth consultation, where I am being provided with services through an online or mobile phone experience. I understand that this is called “telehealth”, since I am not in the same location as the person providing the services. My health care provider has explained to me how the video conferencing technology will be used to affect such a consultation will not be the same as a direct patient/health care provider visit due to the fact that I will not be in the same room as my health care provider.
  2. I understand there are potential risks to this technology, including interruptions, unauthorized access and technical difficulties. I understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.
  3. I understand that my healthcare information may be shared with other individuals for scheduling, my care and billing purposes. The above‐mentioned people will all maintain confidentiality of the information obtained. 
  4. In an emergency situation, I understand that the responsibility of the telehealth provider may include advising my local practitioner or that of emergency or 911 services. 
  5. I understand that billing will occur from the telehealth provider, or from someone on such provider’s behalf and that payment is due regardless of my ability to get reimbursed from insurance.
  6. I have had the opportunity to ask questions in regard to this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.

I certify:

  • That I have read or had this form read and/or had this form explained to me
  • That I fully understand its contents including the risks and benefits of the procedure(s). 
  • That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.
  • That I hereby give consent to telehealth as an acceptable form of delivering healthcare services to me and  that this consent will cover any and all of my sessions using telehealth.