Telehealth Consent Form

Please read the following information regarding telehealth consultations carefully.

1. Purpose of Telehealth

Telehealth involves the use of electronic communication to enable health and wellness services remotely, including consultation, assessment, treatment, and education. It includes interactions via video, phone calls, or other secure platforms.

By signing this form, you consent to participate in telehealth services provided by our practice.

2. Nature of Telehealth Services

Telehealth may include:

- Live audio and video sessions.

- Review of health records, medical history, and other relevant information.

- Discussions and recommendations for wellness, treatment, or follow-up care.

3. Benefits and Limitations

Benefits:

- Access to care from the comfort of your home.

- Continuity of care when in-person visits are not possible.

Limitations:

- Telehealth may not be appropriate for all conditions.

- There may be risks related to data security, as electronic communication is not always fully secure.

- Technical issues (e.g., poor internet connection) may affect the quality of service.

4. Confidentiality and Privacy

Your privacy is protected under the Health Insurance Portability and Accountability Act (HIPAA). Telehealth sessions will not be recorded without your consent. Your personal information will be kept confidential, except as required by law.

However, you acknowledge that:

- While reasonable measures are taken to ensure the privacy of telehealth sessions, there are potential risks related to data breaches.

- You agree to participate in telehealth from a secure and private location to protect your confidentiality.

5. Your Rights

As a client, you have the right to:

- Withdraw consent for telehealth services at any time without affecting your access to other services.

- Request an in-person visit if preferred (subject to availability).

- Access your health records and request corrections.

6. Payment and Insurance

- You agree to pay for telehealth services as arranged with the practitioner.

- If using insurance, you understand that it is your responsibility to confirm coverage for telehealth services.

7. Consent to Telehealth

By signing below, you acknowledge that:

- You have read and understand the information provided above.

- You consent to receive telehealth services under the terms described.

- You have had the opportunity to ask questions about telehealth and agree to proceed.

Client Signature * Required

Signature

I agree that this electronic signature is legally binding.

Telehealth Consent Form

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