Telehealth Informed Consent

Telehealth Informed Consent
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 my provider will make the determination as to whether telehealth is appropriate based on client need and circumstances. *
I understand that I may opt-out of the telehealth visit at any time. This will not change my ability to receive future care at this office. *
I understand that telehealth services can only be provided to patients, including myself, who are residing in the state of West Virginia at the time of this service. *
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(s), Medicare or Medicaid, and it is my responsibility to check with my insurance plan to determine coverage. *
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 doctors, other 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 records). *
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 me. *
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, or an in-office visit. *
I understand that there will be no recording of any of the online sessions by either party. All information disclosed within the session and written records pertaining to those sessions are confidential. *
I understand that electronic communication may be used to communicate highly sensitive medical information, such as treatment for or information related to addiction treatment (alcohol, drug dependence, etc.) *
I understand that I am responsible for using a location that is private and free from distractions or intrusions. *
To the extent permitted by law, I agree to waive and release my healthcare provider and his or her institution or practice from any claims I may have about the telehealth visit. *
I understand that electronic communication should never be used for emergency communication or urgent requests. Emergency communications should be made to the provider's office or to the existing emergency 911 services in my community. *
I understand that my healthcare provider may need to contact my emergency contact and/or the appropriate authorities in case of an emergency. *

Emergency Protocols
I need to know your location in case of an emergency. You agree to inform me of the address where you are at the beginning of each session. I also need a contact person who I may contact on your behalf in a life-threatening emergency only. This person will only be contacted to go to your location for a well check or take you to the hospital in the event of an emergency.
Physical Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Emergency Contact Name *

First Name Last Name
Emergency Contact Phone *
Please enter a valid phone number.
I certify that I have read and understand this agreement and that all blanks were filled in prior to my signature with the opportunity to have questions answered to my satisfaction.
For electronic communications between (Healthcare provider's name)* and staff an(Patient's Name)*
Patient or Legal Guardian Signature *

Clear
Relationship to Patient *
Print Patient or Legal Guardian Name *

First Name Last Name
Date *

Month Day Year
Date
Should be Empty:

Telehealth Informed Consent

Emergency Protocols