Telehealth Consent

This consent describes telehealth services offered by your health care practice (your "Practice") and the rights and responsibilities that apply to them. Please read it carefully before signing.

1. What Telehealth Is

Telehealth is the delivery of health care services using interactive audio, video and other electronic communications so that you and your provider can interact when you are not in the same location. Telehealth may be used for consultations, follow-up visits, review of laboratory results, treatment-plan adjustments, education and monitoring, as determined by your provider.

2. Expected Benefits

• Access to care without travel, including for follow-up visits and brief check-ins.
• Timelier review of results and treatment adjustments.
• Participation of family members or caregivers, with your permission.

3. Possible Risks and Limitations

• Information transmitted may not be sufficient to allow for appropriate decision-making by your provider, such as when a physical examination is needed.
• Delays in evaluation or treatment could occur due to equipment failure or connectivity problems.
• In rare instances, security protocols could fail, resulting in a privacy breach.
• Telehealth may not be appropriate for every condition. Your provider may decide that an in-person visit is necessary and will tell you if so.

4. Your Rights

4.1 You may withhold or withdraw this consent at any time without affecting your right to future care or treatment.

4.2 You may stop a telehealth visit at any time. Your provider may also end a visit if telehealth is not appropriate for your needs.

4.3 You have the right to request an in-person visit instead of telehealth.

4.4 Your health information shared during telehealth is protected under HIPAA and your Practice's Notice of Privacy Practices in the same manner as information shared during in-person care. Telehealth visits are not recorded unless you and your provider agree in advance.

5. Your Responsibilities

• Confirm your location at the start of each visit; your provider must be appropriately licensed for the state you are in.
• Choose a private, quiet location and a reliable connection.
• Provide accurate and complete information about your health, medications and supplements.
• Have a plan for emergencies: if an urgent situation arises during or after a visit, call your local emergency number or go to the nearest emergency facility.

6. Technology and Fees

Video visits are conducted through a service connected to your Practice's platform. You are responsible for your own device and internet connection. Telehealth visits are billed according to your Practice's fee schedule or membership terms, which your Practice will explain before the visit.

7. Consent

By typing my name below, I confirm that I have read and understand this consent, that my questions have been answered, and that I voluntarily consent to receive health care services through telehealth from my Practice under the terms described above. I understand I may revoke this consent at any time by notifying my Practice.

This document is a pre-release draft provided for review and has not yet been approved by legal counsel. A final version will be published and, where required, re-acceptance requested.