Telehealth Consent Form Template: Rights, Risks & Privacy

Telehealth Consent Form

1. Patient Information

Full Name: _____________________________________

Date of Birth: _______________

Phone Number: _____________________________________

Email Address: _____________________________________

Address: _____________________________________

2. Purpose of Telehealth

I understand that telehealth involves the use of secure video, phone, or other electronic communications to provide healthcare services remotely, including:

• Consultation

• Diagnosis

• Treatment

• Follow-up care

Consultation

Diagnosis

Treatment

Follow-up care

3. Provider Responsibilities

My healthcare provider will:

• Explain the telehealth process and answer any questions

• Protect my privacy and confidentiality

• Document the visit in my medical record

• Inform me of limitations of telehealth and recommend in-person care when needed

Explain the telehealth process and answer any questions

Protect my privacy and confidentiality

Document the visit in my medical record

Inform me of limitations of telehealth and recommend in-person care when needed

4. Patient Responsibilities

As the patient, I agree to:

• Be located in a private, safe environment during the session

• Provide accurate and complete information

• Use technology responsibly and reliably

• Not record the session unless mutually agreed

Be located in a private, safe environment during the session

Provide accurate and complete information

Use technology responsibly and reliably

Not record the session unless mutually agreed

5. Risks and Limitations

I understand that:

• Technical failures may occur (e.g., disconnection, poor video/audio quality)

• Telehealth may not be as complete as in-person care

• In rare cases, confidential information could be accessed by unauthorized persons

• I may need in-person follow-up or emergency services

Technical failures may occur (e.g., disconnection, poor video/audio quality)

Telehealth may not be as complete as in-person care

In rare cases, confidential information could be accessed by unauthorized persons

I may need in-person follow-up or emergency services

6. Confidentiality

Telehealth communications are protected by law and follow HIPAA or equivalent local data protection regulations.

All reasonable steps will be taken to maintain the security of my health data.

7. Fees and Insurance

• Fees for telehealth may differ from in-person visits

• My insurance may or may not cover telehealth services

• I am responsible for any charges not covered by my insurance

Fees for telehealth may differ from in-person visits

My insurance may or may not cover telehealth services

I am responsible for any charges not covered by my insurance

8. Consent and Acknowledgment

By signing below, I acknowledge that I:

• Have read and understood the information above

• Had the opportunity to ask questions

• Consent to receive healthcare services via telehealth

• Understand I can withdraw my consent at any time by notifying my provider

Have read and understood the information above

Had the opportunity to ask questions

Consent to receive healthcare services via telehealth

Understand I can withdraw my consent at any time by notifying my provider

Patient Signature

Name:

Date:

Provider / Clinic Representative Signature

Name:

Title:

Date: