Telehealth Services Consent Form "*" indicates required fields Name* First Last Consent* I agree to followingI hereby consent to engaging in telehealth services. I understand that "telehealth" includes the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, or data communication. I understand that telehealth also involves the communication of my medical information, both orally and visually, to health care practitioners located in other sites. I understand that I have the following rights with respect to telehealth: I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment. The laws that protect the confidentiality of my medical information also apply to telehealth. As such, I understand that the information disclosed by me during the course of my therapy is generally confidential. I understand that there are risks and consequences from telehealth, including, but not limited to, the possibility, despite reasonable efforts on the part of my physician, that the transmission of my medical information could be disrupted or distorted by technical failures. I understand that telehealth-based services and care may not be as complete as face-to-face services. I also understand that if my physician believes I would be better served by another form of psychotherapeutic services (e.g. face-to-face services), I will be referred to a physician who can provide such services in my area. I understand that I may benefit from telehealth, but results cannot be guaranteed or assured. I have read and understand the information provided above. I have had an opportunity to ask questions about this information, and all of my questions have been answered. I hereby give my informed consent for the use of telehealth in my medical care. This consent form is subject to renewal annually.Signature*CommentsThis field is for validation purposes and should be left unchanged.
