I hereby declare that I am of legal age and quipped of my mental faculties to give my consent. I have had the opportunity to ask questions and clarifications, and by which I have received answers to my satisfaction. I declare that I have disclosed my entire medical history on the forms provided. Your Favorite Nurse Practitioner or none of their owners or employees hold any responsibilty related to my health outcomes. I agree I am of sound mind and have been in no way forced to choose a Telehealth option for healthcare. This choice was merely for convience. Your Favorite Nurse Practitioner is not my primary care provider. 

HIPAA Privacy & Confidentiality Statement
(Telehealth Services)

Notice of Privacy Practices & Patient Acknowledgment

This practice is committed to protecting the privacy, confidentiality, and security of your protected health information (PHI) in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and all applicable federal and state laws.

Use and Disclosure of Protected Health Information
Your protected health information may be used and disclosed for purposes of treatment, payment, and healthcare operations. This includes providing telehealth medical services, coordinating care, documenting medical records, processing billing, and maintaining quality assurance. Information may be shared with other healthcare providers, laboratories, pharmacies, or third-party service providers as necessary to support your care, in compliance with HIPAA regulations.

Telehealth services may involve the electronic transmission of health information using secure, HIPAA-compliant platforms. While every effort is made to protect your information, you acknowledge that no electronic transmission can be guaranteed to be 100% secure.

Patient Rights
You have the right to:
Request confidential communications
Receive a copy of this Notice of Privacy Practices upon request
Safeguards
This practice implements administrative, physical, and technical safeguards to protect your health information. All telehealth sessions are conducted using secure technology designed to comply with HIPAA privacy and security standards.

Authorization
Your information will not be used or disclosed for purposes outside of treatment, payment, or healthcare operations without your written authorization, except as required or permitted by law.

Complaints
If you believe your privacy rights have been violated, you have the right to file a complaint with this practice or with the U.S. Department of Health and Human Services without fear of retaliation.

Acknowledgment
By signing the Consent to Treatment form, you acknowledge that you have been informed of your rights under HIPAA, understand how your protected health information may be used and disclosed, and consent to the use of telehealth services.