Telehealth Consent Form

Purpose: This form is intended to obtain informed consent from a patient to participate in healthcare services provided via telehealth technologies. Telehealth allows patients to consult healthcare providers remotely using video conferencing, audio communication, and digital transmission of medical information.

Patient Information

Full Name: {fullName}

Date of Birth: {dateOfBirth}

Address: {address}

Phone Number: {phoneNumber}

Email: {email}

Telehealth Description

Telehealth involves the use of electronic communications to enable healthcare providers to evaluate, diagnose and treat patients remotely. Services may include:

{#telehealthServices}

• {service}

{/telehealthServices}

Consent Terms

• I understand that telehealth is the use of electronic information and communication technologies by a healthcare provider to deliver services to a patient when they are located at a different site.
• I understand that the laws that protect privacy and the confidentiality of medical information also apply to telehealth.
• I understand that I have the right to withhold or withdraw my consent to the use of telehealth at any time, without affecting my right to future care or treatment.
• I understand that I may expect the anticipated benefits from the use of telehealth in my care, but that no results can be guaranteed.

Risks and Limitations

Potential risks associated with the use of telehealth include, but may not be limited to:

{#telehealthRisks}

• {risk}

{/telehealthRisks}

Patient Attestation

By signing this form, I acknowledge and agree to the following:

• I have read this form and had an opportunity to ask questions.
• My questions have been answered to my satisfaction.
• I consent to receive healthcare services via telehealth from {providerName} and affiliated healthcare professionals.

Insurance Details

{#hasInsurance}

Insurance Provider: {insuranceProvider}

Policy Number: {policyNumber}

{/hasInsurance}

{^hasInsurance}

The patient has indicated that they do not currently have health insurance coverage.

{/hasInsurance}

Emergency Contact

Signature

Patient Signature: ___________________________

Date: {signatureDate}

Provider Name: {providerName}

Note: A copy of this signed consent form will be provided to the patient upon request.