1. Introduction
You are being asked to read and sign this form prior to participating in treatment via telehealth. The purpose of this form is to inform you about your rights, the nature and risks of telehealth, and to obtain your consent for treatment using this method.
2. Definition of telehealth
Telehealth is the delivery of healthcare services using electronic communications, information technology, or other means between a healthcare provider and a patient who are not in the same physical location. This may include:
- Consultation via video conferencing
- Communication through phone calls, secure messaging, and emails
- Remote monitoring of health data (if applicable)
3. Purpose and benefits
Telehealth allows for:
- Improved access to care by enabling you to connect with licensed providers remotely
- More flexible scheduling
- Reduced travel time and cost
- Continuity of care when in-person services are not feasible
4. Risks and limitations
While telehealth offers many benefits, it also presents risks, including but not limited to:
- Technical failures such as loss of internet connection, image or sound distortion, or software issues
- Delayed evaluation due to lack of access to certain diagnostic tools
- Breaches of confidentiality due to insecure technology or unintentional disclosure
- Potential miscommunication due to limited visual or auditory cues
5. Privacy and confidentiality
Your rights to confidentiality and privacy are protected by federal and state laws, including HIPAA. Efforts will be made to ensure the security of telehealth communications. However, there are circumstances beyond the provider's control that may compromise confidentiality, including but not limited to:
- Use of unsecured or public Wi-Fi
- Unauthorized access by others on your device
- Limitations in the provider's or your technology
You are responsible for using a private and secure location for telehealth sessions and for protecting your own device from unauthorized access.
6. Emergencies
Telehealth is not appropriate for medical or mental health emergencies. If you are experiencing an emergency, you should call 911 or go to the nearest emergency room.
Your provider may require the name and phone number of a person to contact in case of an emergency, as well as your physical location during each telehealth session.
7. Patient rights
You have the right to:
- Refuse or withdraw consent to telehealth at any time without affecting your right to future care or treatment
- Ask questions about telehealth procedures
- Request a copy of this consent form
- Access your medical records as provided by law
8. Provider licensure
You confirm that you are physically located in a state where your provider is licensed to practice. If your location changes, you agree to notify your provider prior to the session.
9. Billing and insurance
You understand:
- That telehealth visits may be billed to your insurance if applicable
- That some insurance providers may not cover telehealth or may reimburse at different rates
- That you may be responsible for all charges that are not covered by your insurance
10. Consent to telehealth treatment
By agreeing, you acknowledge and agree to the following:
- I have read, understood, and agree to the terms described above
- I understand the nature, purpose, benefits, and risks of telehealth
- I consent to participate in telehealth services provided by my healthcare provider
- I understand that I can withdraw my consent at any time
Last Updated: 05/01/2025