Permission for Telehealth Visits

• This Telehealth Consent Form is required if you wish to use telehealth for online, telephone, and video consultations.
• This Form requires your signature at the end to grant us telehealth permission.

What is telehealth?

Telemedicine involves the use of electronic communication technologies by a health care provider to deliver health care services to a patient when the patient and provider are at different locations.

Benefits: Potential benefits of telemedicine include improved access to health care

Risks:   I understand that there are potential risks associated with the use of technology for telemedicine services, including but not limited to:

 • The video connection may not work, or may stop working during the telemedicine visit;

 • The video or sound may not be clear enough to be useful to effectively complete the telemedicine visit;

 • I may need to reschedule an in-person visit if the health care provider believes the information able to be obtained during the telemedicine visit is not sufficient;

 • Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment;

 • Security protocols could fail, causing a breach of privacy of personal medical information.

Do I have to sign this document?

• No. Only sign this document if you want to use telehealth.

What does it mean if I sign this document?

If you sign this document, you agree that:

• We talked about the information in this document.
• We answered all your questions.
• You want a telehealth visit.

 If you sign this document, we will give you a copy.