Telehealth Consent Template

TELEHEALTH CONSENT FORM

Date: Date

Healthcare Provider/Practice: Provider/Practice Name

Address: Address Phone: Phone Email: Email Website: Website

Patient Information:

Name: Patient Full Name

Date of Birth: DOB Patient ID: ID Number Address: Address Phone: Phone Email: Email

1. DEFINITION OF TELEHEALTH

Telehealth (also called telemedicine) 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.

Telehealth May Include:

• Live video conferencing
• Secure messaging
• Remote patient monitoring
• Store-and-forward imaging
• Mobile health apps
• Telephone consultations

2. SERVICES PROVIDED VIA TELEHEALTH

The following services may be provided through telehealth:

• Medical consultations and follow-ups
• Mental health counseling/therapy
• Medication management
• Chronic disease management
• Health coaching
• Other services specific to provider

Services NOT Available via Telehealth:

• Physical examinations requiring in-person assessment
• Procedures
• Emergency care
• Other limitations

3. TECHNOLOGY REQUIREMENTS

Patient Responsible For:

• Reliable internet connection
• Device with camera and microphone (smartphone, tablet, or computer)
• Private, quiet location for appointment
• Adequate lighting
• Specific platform/software: Name

Platform Used:

Name of telehealth platform

• HIPAA-compliant: Yes
• End-to-end encrypted: Yes/No
• Download required: Yes/No

Technical Support:

For technical issues: Support contact Available: Hours

4. BENEFITS OF TELEHEALTH

Potential Benefits Include:

• Increased access to healthcare
• Convenience (no travel required)
• Reduced exposure to illnesses
• Continuity of care from home or other location
• May reduce time off work
• May be more comfortable discussing sensitive topics
• Access to specialists regardless of location

5. LIMITATIONS AND RISKS

Limitations:

• Provider cannot perform physical examination
• Technology may fail or be interrupted
• Not appropriate for emergencies
• Some diagnoses may require in-person visit
• Prescribing limitations (certain controlled substances)
• May not be able to see or hear all necessary clinical information

Potential Risks:

• Technology failures or interruptions
• Inadequate internet connection affecting quality
• Security risks despite safeguards (see Security section)
• Delays in evaluation or treatment
• Misdiagnosis or missed diagnosis due to lack of in-person exam
• Information transmitted could be incomplete
• Possibility of being overheard if privacy not ensured

I Understand:

In-person visit may be necessary if:

• Physical examination needed
• Telehealth consultation is insufficient
• Emergency situation arises
• Provider determines in-person visit is appropriate

6. PRIVACY AND SECURITY

HIPAA Compliance:

This telehealth service is HIPAA-compliant and protects your health information.

Security Measures:

• Encrypted video and data transmission
• Secure, password-protected platform
• No recording without consent
• Secure data storage
• Other security measures

Patient Responsibilities for Privacy:

• Use telehealth from private location
• Do not allow others to see or hear session
• Ensure your device is secure (password, updated software)
• Do not share login credentials
• Use secure internet connection (not public Wi-Fi)

Despite Security Measures:

There is a possibility that transmitted information could be intercepted, accessed, or breached. While unlikely, patients should be aware of this risk.

Recording:

Sessions are NOT recorded unless:

• You provide explicit consent
• Required for documentation (with consent)
• For education/quality improvement (de-identified, with consent)

I consent to session recording (if applicable):

• Yes, for the following purposes: Medical records/Education/Other
• No

7. EMERGENCY PROTOCOLS

Telehealth is NOT for Emergencies

In Case of Emergency:

• Call 911 or go to nearest emergency room
• Do not wait for telehealth response
• For psychiatric emergencies: Crisis line number

Provider Will:

• Ask for your physical location at start of each session
• Maintain emergency contact information
• Have plan for handling emergencies during session

I Provide the Following Emergency Information:

• Current physical location: Address
• Emergency contact: Name and phone
• Local emergency services: 911 or Local number

If Emergency During Telehealth Visit:

Provider may:

• Instruct you to call 911
• Contact emergency services on your behalf
• Contact your emergency contact
• Direct you to nearest emergency facility

8. INFORMED CONSENT FOR TREATMENT

I Understand:

• Telehealth is an alternative to in-person visits
• The same standards of care apply
• I have the right to refuse telehealth and request in-person visit
• My healthcare provider may determine that in-person visit is necessary
• I should provide complete and accurate information
• I should ask questions if I don't understand

Decision-Making:

Clinical decisions are based on information I provide and what provider observes via telehealth technology.

9. PROVIDER QUALIFICATIONS

Provider Information:

Name: Provider Name

Credentials: MD, DO, NP, PA, LCSW, PhD, etc. License Number: Number License State: State

Verification:

You may verify provider credentials at: State licensing board website

Supervision (if applicable):

If provider is supervised, name and credentials of supervising provider

10. PATIENT RESPONSIBILITIES

Before Appointment:

• Test technology in advance
• Ensure quiet, private, well-lit location
• Have list of current medications ready
• Prepare questions or concerns
• Have pharmacy information available
• Gather any relevant medical records

During Appointment:

• Be on time (log in at scheduled time)
• Be in a private location
• Minimize distractions
• Provide accurate information
• Ask questions if unclear
• Follow provider instructions

After Appointment:

• Review visit summary/instructions
• Fill prescriptions as directed
• Schedule follow-up if needed
• Report any problems or concerns
• Complete any requested monitoring or testing

11. PRESCRIPTIONS

Provider May:

• Prescribe medications as appropriate
• Send prescriptions electronically to pharmacy of choice
• Provide refills for ongoing medications

Limitations:

• Some medications cannot be prescribed via telehealth
• Controlled substances: State-specific limitations
• New prescriptions may require in-person visit
• DEA regulations must be followed

Pharmacy:

Preferred pharmacy: Pharmacy name and location Phone: Phone

12. SCHEDULING AND CANCELLATION

Scheduling:

• Book appointments via: Phone/Website/Patient portal
• Confirmation sent via: Email/Text/Phone
• Reminder sent: Timeframe before appointment

Cancellation Policy:

• Cancel at least X hours in advance
• Late cancellation fee: Amount (if applicable)
• No-show fee: Amount (if applicable)
• How to cancel: Phone/Portal/Email

Late/Missed Appointments:

• If you are more than X minutes late, appointment may be canceled
• If provider is late, appointment extended or rescheduled

13. FEES AND INSURANCE

Telehealth Visits:

• Covered by insurance (verify with your insurer)
• Self-pay: Amount
• Copay: Amount
• Other payment arrangement

Insurance Coverage:

• Many insurers now cover telehealth
• Coverage varies by state and plan
• Patient responsible for verifying coverage
• Patient responsible for copays/deductibles

Payment:

• Due at time of service
• Methods accepted: Credit card/HSA/FSA/Other
• Billing questions: Contact information

I Understand:

I am financially responsible for services regardless of insurance coverage.

14. CONTINUITY OF CARE

Medical Records:

• Telehealth visits documented in medical record
• Same confidentiality as in-person visits
• You have right to access your records
• Records shared with other providers only with your consent (except as required by law)

Coordination of Care:

• May coordinate with your primary care provider (with consent)
• Referrals to specialists if needed
• Test results communicated per practice policy

Ongoing Care:

• Regular follow-up scheduled as needed
• Mix of telehealth and in-person visits as appropriate
• Continuity maintained

15. COMMUNICATION BETWEEN VISITS

Secure Messaging:

Available via: Patient portal/Platform Use for: Non-urgent questions and messages Response time: Within X business days

Phone Calls:

• Urgent issues: Phone number
• Prescription refills: Process
• Billing questions: Phone number

After-Hours:

• Non-emergency nurse line: Number (if applicable)
• Leave message for callback: Number
• Emergency: Call 911

NOT for Time-Sensitive or Emergency Matters

16. PATIENT RIGHTS

I Have the Right To:

• Refuse telehealth and request in-person visit without affecting my care
• Participate in decision-making
• Ask questions and receive answers
• Privacy and confidentiality
• Access my medical records
• End telehealth session at any time
• File a complaint
• Withdraw consent for telehealth at any time

To Withdraw Consent:

Contact Provider office to schedule in-person visits instead.

17. PROVIDER RIGHTS

Provider Reserves the Right To:

• Determine if telehealth is appropriate for specific situation
• Require in-person visit when clinically indicated
• Terminate telehealth relationship with notice (except in emergency)
• Refuse services if patient is intoxicated or disruptive

18. JURISDICTION AND LICENSURE

Telehealth Across State Lines:

Provider must be licensed in the state where patient is located at time of service.

I Confirm:

I am physically located in State during telehealth appointments.

I Will Notify Provider If:

I am in a different state for scheduled appointment.

19. COMPLAINTS AND GRIEVANCES

If Dissatisfied:

Contact: Practice manager/Compliance officer Phone: Phone Email: Email

Professional Complaints:

May file complaint with state licensing board: Name of board Website Phone

20. CONSENT DURATION AND MODIFICATION

This Consent:

• Remains in effect for all future telehealth visits
• Can be revoked at any time
• May be updated; changes communicated

Changes to Telehealth Services:

Provider may modify telehealth services with notice. Continued use indicates acceptance of changes.

21. ACKNOWLEDGMENTS AND AGREEMENT

I Acknowledge and Agree That:

• I have read and understand this consent form
• I have had opportunity to ask questions
• My questions have been answered
• I understand the benefits and risks of telehealth
• I understand the limitations of telehealth
• I understand the alternatives (in-person visits)
• I consent to receive healthcare services via telehealth
• I understand I may withdraw consent at any time
• I am voluntarily consenting to telehealth
• I will provide accurate information and comply with recommendations
• I understand this is not for emergencies
• I will ensure privacy during sessions
• I am financially responsible for services

SIGNATURES:

Patient (or Authorized Representative):

Signature: _______________________

Printed Name: Name

Date: _______________________

If Signed by Representative:

Relationship to Patient: Parent/Guardian/Healthcare Proxy/Other Authority to Consent: Legal basis

Provider/Designee:

I have explained telehealth services, risks, benefits, and alternatives. I have answered patient's questions.

Signature: _______________________

Printed Name: Name

Title: Title

Date: _______________________

Minor Patient (if applicable and age-appropriate):

I assent to telehealth services.

Signature: _______________________

Printed Name: Name Age: Age

Date: _______________________