Telehealth Consent

1. Purpose of Telehealth Consultation

I understand that I am participating in a telehealth consultation to evaluate my medical history, symptoms, and health goals to determine eligibility for healthcare services and treatments, which may include prescription medications, wellness therapies, or other medical recommendations as deemed appropriate by my provider. I acknowledge that:

• The evaluation will be conducted remotely using video, phone, secure messaging, digital questionnaires, images, or record review.
• My provider relies on the accuracy and completeness of the information I provide to make informed clinical decisions.
• A telehealth consultation does not guarantee approval for any specific treatment or medication.
• Additional information, laboratory testing, or in-person evaluation may be required before treatment or prescribing.

2. Nature of Telehealth Services

I understand that:

• Telehealth involves the use of electronic communication technologies to evaluate, diagnose, and manage healthcare.
• A traditional in-person physical examination will not be performed as part of telehealth services.
• Care may be provided through synchronous (real-time video or phone) and/or asynchronous (questionnaires, images, messages, or record review) methods.
• Third-party telemedicine platforms may be used to deliver care, and my medical information may be stored electronically for documentation and continuity of care.
  

3. Risks and Limitations of Telehealth

I acknowledge that telehealth has limitations and potential risks, including but not limited to:

• Incomplete evaluation due to the absence of an in-person physical exam.
• The possibility that certain conditions may require in-person assessment or referral.
• Technical issues or interruptions that may affect communication.
• Delays in medical decision-making if additional information or testing is needed.
• Potential privacy risks inherent to electronic communications despite reasonable security measures.
  

4. Privacy, Confidentiality, and HIPAA

I understand that:

• My health information is protected under applicable state and federal privacy laws, including HIPAA.
• My information will not be disclosed without my authorization unless required by law.
• I am responsible for taking reasonable steps to ensure privacy on my end, such as using secure internet connections and participating in telehealth visits from a private location.
  

5. Alternatives to Telehealth

I understand that:

• Telehealth is voluntary, and I may choose to seek in-person medical care instead.
• I am not obligated to proceed with telehealth services if I prefer an in-person evaluation.
• Alternative treatment options may be available depending on my condition and clinical findings.
  

6. Consent to Services and Financial Responsibility

I consent to receiving healthcare services via telehealth. I understand that telehealth services may be limited to evaluation, clearance, or treatment recommendations and may not constitute ongoing primary or specialty care unless otherwise specified. If treatment is recommended or prescribed, I understand that I am responsible for:

• Medication costs if not covered by insurance.
• Required laboratory testing, follow-up visits, or additional evaluations.
• Following all medical instructions and treatment guidelines provided by my healthcare provider.
  

7. Acknowledgment and Consent

By submitting this form, I confirm that:

• I have read and understand this Telehealth Consent.
• I have had the opportunity to ask questions.
• I understand the risks, benefits, and limitations of telehealth services.
• I voluntarily consent to receive healthcare services.

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