Telehealth Consent for Disability Benefits Questionnaire (DBQ) Evaluation

You are requesting a telehealth medical evaluation for the purpose of completing a Disability Benefits Questionnaire (DBQ) or similar medical documentation related to a federal or veterans’ disability claim.

 This encounter is limited to medical evaluation and documentation only and is not intended to establish ongoing medical care.

Telehealth involves the use of secure audio and/or video communication technology to conduct a medical evaluation remotely. The telehealth visit may include:

• Review of medical history and records you provide,
• Discussion of symptoms, functional limitations, and medical history, and
• Clarifying questions necessary to complete the DBQ accurately.

No physical, hands-on examination will be performed.

You understand and agree that:

• This telehealth visit is conducted solely for the purpose of completing a DBQ or medical opinion.

• This evaluation does not establish a physician-patient relationship.

• No diagnosis, treatment plan, prescriptions, or medical management will be provided.

• The evaluating physician’s role is limited to offering an independent medical opinion based on:

• Your reported history, 
• Available medical records, and
• Medical expertise and professional judgment.

Completion of a DBQ does not guarantee approval of a disability claim or benefits.

You acknowledge that telehealth has inherent limitations, including but not limited to:

• Inability to perform a hands-on physical examination,
• Potential technical issues (e.g., connectivity problems), and 
• Reliance on the accuracy and completeness of information you provide.

You agree to promptly notify the physician if you experience technical difficulties during the visit.

Reasonable efforts are made to ensure the privacy and security of telehealth communications.

Despite safeguards, there is a small risk of unauthorized access or technical failure.

You agree to participate from a private location where your information cannot be overheard.

Your medical information will be handled in accordance with applicable privacy laws.

Telehealth DBQ evaluations are not appropriate for emergencies.

If you are experiencing a medical emergency, you should call 911 or seek immediate in-person medical care.

Participation in this telehealth DBQ evaluation is voluntary. You may:

• Decline telehealth services, and/or
• Withdraw consent at any time prior to or during the encounter.

However, declining or withdrawing consent will prevent completion of the DBQ, since an examination is required by the VA (Section in order to complete the DBQ.

By submitting this form,you acknowledge that:

• You requested that our physician complete your VA Disability Benefits Questionnaire, for which the VA requires an examination. 
• You have read and understand this Telehealth Consent.
• You had the opportunity to ask questions.
• You consent to participate in a telehealth medical evaluation for DBQ purposes.
• You understand the scope and limitations of this service.