J12355 3/20
This form is for reference purposes only. It is a general guideline and not a statement of standard of care
and should be edited and amended to reflect policy requirements of your practice site(s), CMS,
and accreditation requirements, if any, and legal requirements of your individual state(s).
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.
Patient’s
Initials
_____ I understand that telehealth involves the communication of my medical/mental health
information in an electronic or technology-assisted format.
_____ 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 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 Skype, FaceTime, or a similar service may not provide a secure
HIPAA-compliant platform, but I willingly and knowingly wish to proceed.
J12355 3/20
This form is for reference purposes only. It is a general guideline and not a statement of standard of care
and should be edited and amended to reflect policy requirements of your practice site(s), CMS,
and accreditation requirements, if any, and legal requirements of your individual state(s).
_____ 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 agree that I have verified to my healthcare provider my identity and current location
in connection with the telehealth services. I acknowledge that failure to comply with
these procedures may terminate the telehealth visit.
_____ I understand that I have a responsibility to verify the identity and credentials of the
healthcare provider rendering my care via telehealth and to confirm that he or she is
my healthcare provider.
_____ I understand that electronic communication cannot be used for emergencies or time-
sensitive matters.
_____ 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, a biopsy, or an in-office visit.
_____ I understand that electronic communication may be used to communicate highly
sensitive medical information, such as treatment for or information related to
HIV/AIDS, sexually transmitted diseases, or addiction treatment (alcohol, drug
dependence, etc.).
_____ I understand that my healthcare provider may choose to forward my information to an
authorized third party. Therefore, I have informed the healthcare provider of any
information I do not wish to be transmitted through electronic communications.
_____ By signing below, I understand the inherent risks of errors or deficiencies in the
electronic transmission of health information and images during a telehealth visit.
_____ I understand that there is never a warranty or guarantee as to a particular result or
outcome related to a condition or diagnosis when medical care is provided.
_____ 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
communications or urgent requests. Emergency communications should be made to
the provider’s office or to the existing emergency 911 services in my community.
J12355 3/20
This form is for reference purposes only. It is a general guideline and not a statement of standard of care
and should be edited and amended to reflect policy requirements of your practice site(s), CMS,
and accreditation requirements, if any, and legal requirements of your individual state(s).
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 communication between and staff and .
(Healthcare provider’s name) (Patient’s name)
Patient or Legal Representative Signature/Date/Time Relationship to Patient
Print Patient or Legal Representative Name Witness Signature/Date/Time
I certify that I have explained the nature of this agreement to the patient/patient’s legal
representative. I have answered all questions fully, and I believe that the patient/legal
representative (circle one) fully understands what I have explained.
Healthcare Provider Signature/Date/Time
copy given to patient original placed in chart
initial initial
Optional National Emergency Crisis Language
I understand that due to the state of the current national emergency crisis, telehealth is offered by
to appropriate patients in an effort to comply with federal and state
mandates of isolation and social distancing as an effort to provide protection to everyone.
The purpose of this form is to obtain your consent for a telehealth visit with one of our healthcare
providers at the office of .
The purpose of this visit is for the care of during the national emergency.
(condition/treatment)
