Purpose of this Telehealth Services Consent Form is to explain patients and their parents/guardians about the benefits and risks of telehealth services, inform them about their rights and confidentiality, and collect permissions from patients or their parents/guardians in order to participate into telehealth services.
2. Telehealth Services
Telehealth is an online delivery of healthcare services which does not require for patients and doctors to be in the same physical location (i.e. doctor's office). Through the videoconference technology, telehealth practice/treatment is provided by healthcare practitioners, specialists, and professionals. Interactive appointments are held via teleconference software that includes video and audio supported communication.
Patients can access the healthcare services in remote sites thanks to telehealth technology.
The quality of the videoconference during appointments may not be sufficient due to internet speed. Hence, information transferred may not be sufficient enough as in the physical doctor's visit due to the low quality of videos or images.
Because third party teleconference software is used during online doctor's visits, failures can occur in security protocols that may cause exposure of private medical and personal information.
Medical and personal information of patients is kept private and protected by the state and governmental laws.
6. Patient Rights
Patients can withdraw or withhold this consent at any time. Any action will not affect the future treatment of patients. Patients can ask any question regarding telehealth services, treatment process, and appointments before, during, or after the treatment.
Patients accept they are responsible for additional charges or co-payments that their insurance providers do not cover.
I have been informed about the benefits, risks, rights, and privacy of my medical and personal information during telehealth practice. I have understood all the terms and risks of exposure of my information due to unexpected failures in security. I hereby authorize and give my consent to the healthcare services to use telehealth technology during my treatment.