Telehealth is healthcare provided by any means other than a face-to-face visit. In telehealth services, medical and mental health information is used for diagnosis, consultation, treatment, therapy, follow-up, and education. Health information is exchanged interactively from one site to another through electronic communications. Telephone consultation, videoconferencing, transmission of still images, e-health technologies, patient portals, and remote patient monitoring are all considered telehealth services.

• I understand that telehealth involves the communication of my medical/mental health information in an electronic or technology-assisted format. I understand that telehealth services can only be provided to patients, including myself, who are residing in the state of Massachusetts or New Hampshire.
• I understand that telehealth billing information is collected in the same manner as a regular office visit. My financial responsibility will be determined individually and governed by my insurance carrier. 
• I understand that all electronic medical communications carry some level of risk. While the likelihood of risks associated with the use of telehealth in a secure environment is reduced, the risks are nonetheless real and important to understand. These risks include but are not limited to:
  • It is easier for electronic communication to be forwarded, intercepted, or even changed without my knowledge and despite taking reasonable measures.
  • Electronic systems that are accessed by employers, friends, or others are not secure and should be avoided. It is important for me to use a secure network.
  • Despite reasonable efforts on the part of my healthcare provider, the transmission of medical information could be disrupted or distorted by technical failures.
• I agree that information exchanged during my telehealth visit will be maintained by the healthcare providers, and healthcare facilities involved in my care.
• I understand that medical information, including medical records, are governed by federal and state laws that apply to telehealth. This includes my right to access my own medical records (and copies of medical record.
• I understand that I must take reasonable steps to protect myself from unauthorized use of my electronic communications by others.
• The healthcare provider is not responsible for breaches of confidentiality caused by an independent third party, or by the client.
• I agree that I have verified to my healthcare provider my identity and current location in connection with the telehealth services. I acknowledge that failure to comply with these procedures may terminate the telehealth visit.
• I understand that electronic communication cannot be used for emergencies or time-sensitive matters.
• I understand and agree that a medical evaluation via telehealth may limit my healthcare provider's ability to fully diagnose a condition or disease. As the patient, I agree to accept responsibility for following my healthcare provider's recommendations-including further diagnostic testing, such as lab testing, a biopsy, or an in-office visit.
• By signing below. I understand the inherent risks of errors or deficiencies in the electronic transmission of health information and images during a telehealth visit.
• I understand that there is never a warranty or guarantee as to a particular result or outcome related to a condition or diagnosis when medical care is provided.
• I understand that electronic communication should never be used for emergency communications or urgent requests. Emergency communications should be made to the provider's office or to the existing emergency 911 services in my community.

I certify that I have read and understand this agreement, and can address any future questions with my provider.