Telemedicine Consent Form

Telemedicine Consent Form
TELEMEDICINE PATIENT CONSENT

PURPOSE: The purpose of "Telemedicine Consent Form" is to get the patient's consent in order to participate in appointments of telemedicine cares.

RECORDS: Telecommunications with patients will not be recorded and stored. I hereby authorize Hematology and Oncology Associates of Northern California to use the telehealth practice platform or telecommunication for evaluating, testing and diagnosing my medical condition.

TELEMEDICINE INFORMATION: The medical information related to history, records and tests of the patient will be discussed during the telemedicine appointment with video and audio.

ACCESS: The patient accepts that he/she needs access to PC, laptop, or mobile device and a good internet connection in order to have an efficient telemedicine appointment. I accept that Hematology and Oncology Associates of Northern California will initiate interactive sessions with video call; however, I am informed that the sessions can be conducted via regular voice communication if the technical requirements such as internet speed cannot be met.

PATIENT RIGHTS: The patient can withdraw his/her consent at any time and can ask the questions related to telemedicine appointments and technical requirements for telecommunication.
Patient Name

First Name Last Name
Date of Birth

Month Day Year
Date
Email
example@example.com
Phone Number

Area Code Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Insurance Type
By signing this form,

I understand that all the laws that are protecting my privacy of medical history or information are also applied to telemedicine practices.

I understand that I can withdraw the consent at any time and that will not affect any of my future treatment procedures.

I understand that I can be charged the additional fees that my insurance does not cover.

I accept that I authorize health care professionals and use telemedicine for my treatment and diagnosis.
Date

Month Day Year
Date
Signature

Clear
Should be Empty: