Our practice implements telehealth virtual visits via interactive video conferencing for medical evaluation and management as well as psychotherapy. The necessary frequency and duration of these services will be determined by your provider. All services provided comply with all of the HIPAA Privacy and Security requirements.

1. Purpose. The purpose of this form is to obtain your consent to participate in telehealth services provided.

2. Your Rights. You may withhold or withdraw your consent to the telehealth service at any time before or during the visit without affecting the right to future care or treatment.

3. Risks and Benefits. Please initial to indicate you have read each statement and understand it.
Initial*   I understand that there may be limitations to image quality or other electronic problems that are beyond the control of the provider.

Initial*   I understand that delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment.     
 
Initial*   I understand that in some instances, security protocols could fail, causing a breach of privacy of person medical information.

Initial*   I understand that in lieu of this telehealth encounter, I may seek health care elsewhere where I might have face-to-face contact with the health care provider.

Initial*   I understand that there are no guarantees with telehealth services.

By signing below, I agree that I have received an explanation of how the video and audio technology will be used to conduct the telehealth service, and I understand there are limitations to the technology and the process of telehealth, including the potential for incomplete exchange or loss of information. I understand the written information provided above, and I hereby voluntarily and freely agree and give my consent to take part in the telehealth service and to any related evaluation, assessment and diagnosis as the consulting health care provider deems appropriate.
      

First Name*   Last Name*   Date*      


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