TELEHEALTH INFORMED CONSENT FORM

[// GUIDANCE: This template provides a comprehensive telehealth informed consent compliant with HIPAA and general state telehealth requirements. States have varying consent requirements - California requires written or verbal consent documented in medical record; Texas requires informed consent prior to telehealth services; Georgia Medicaid requires written consent. Customize according to your state's specific requirements.]

PATIENT INFORMATION

Patient Name: [PATIENT FULL LEGAL NAME]

Date of Birth: [DATE OF BIRTH]

Medical Record Number: [MRN]

Address: [PATIENT ADDRESS]

Phone Number: [PHONE NUMBER]

Email Address: [EMAIL ADDRESS]

Emergency Contact: [EMERGENCY CONTACT NAME AND PHONE]

HEALTHCARE PROVIDER INFORMATION

Provider Name: [PROVIDER NAME], [CREDENTIALS]

License Number: [LICENSE NUMBER]

State(s) of Licensure: [STATE(S)]

Practice Name: [PRACTICE NAME]

Practice Address: [PRACTICE ADDRESS]

Phone Number: [PRACTICE PHONE]

Email: [PRACTICE EMAIL]

SECTION 1: NATURE OF TELEHEALTH SERVICES

1.1 Definition of Telehealth

Telehealth involves the use of electronic communications to enable healthcare providers at different locations to share individual patient medical information for the purpose of improving patient care. Telehealth may be used for diagnosis, treatment, follow-up, patient education, and/or care coordination.

[// GUIDANCE: Modify definition based on state law. Some states have specific statutory definitions of "telemedicine," "telehealth," or "telemonitoring" that must be referenced.]

1.2 Types of Telehealth Services Offered

The following types of telehealth services may be provided:

☐ Live video conferencing (synchronous telehealth)
☐ Store-and-forward technology (asynchronous telehealth)
☐ Remote patient monitoring
☐ Audio-only telephone consultations
☐ Secure messaging through patient portal
☐ Mobile health applications
☐ Other: [SPECIFY]

1.3 Technology Requirements

To participate in telehealth services, you will need:

• A device with video and audio capabilities (computer, tablet, or smartphone)
• A stable internet connection
• A private location for your appointment
• Access to the designated telehealth platform: [PLATFORM NAME]

SECTION 2: BENEFITS OF TELEHEALTH

I understand that telehealth may provide the following potential benefits:

☐ Improved access to healthcare, especially in remote or underserved areas
☐ Reduced travel time and associated costs
☐ Decreased exposure to infectious diseases in waiting rooms
☐ Convenience of receiving care from home or another private location
☐ More timely access to medical care
☐ Ability to include family members or caregivers in consultations
☐ Continuity of care when in-person visits are not possible
☐ Access to specialists not available locally

SECTION 3: RISKS AND LIMITATIONS OF TELEHEALTH

3.1 Technical Limitations

I understand the following technical risks and limitations:

☐ Technology failures may interrupt or terminate the telehealth session
☐ Poor internet connection may affect audio/video quality
☐ Security protocols may fail, potentially compromising the privacy of my health information
☐ Delays in evaluation and treatment could occur due to deficiencies in technology
☐ Lack of access to complete medical records may result in adverse drug interactions or allergic reactions

3.2 Clinical Limitations

I understand the following clinical limitations:

☐ The provider cannot perform a physical examination through telehealth
☐ Some conditions may not be appropriate for telehealth diagnosis or treatment
☐ The provider may determine that telehealth is not appropriate for my condition and require an in-person visit
☐ There is a risk of misdiagnosis or delayed diagnosis
☐ The inability to perform certain tests or procedures remotely
☐ Emergency services cannot be provided via telehealth

[// GUIDANCE: Per state telehealth consent requirements (e.g., Texas), patients must be informed of the option to decline telehealth in favor of in-person care. Many states require disclosure of telehealth limitations, especially when lack of physical examination may impact diagnosis.]

3.3 Privacy Risks

I understand the following privacy considerations:

☐ Despite reasonable security measures, electronic communications may be intercepted
☐ Others in my location may overhear conversations if I am not in a private setting
☐ Healthcare information transmitted may become part of my medical record
☐ Third-party platforms may have their own privacy policies

SECTION 4: PATIENT RIGHTS AND RESPONSIBILITIES

4.1 My Rights

I understand that I have the following rights:

☐ The right to withhold or withdraw consent for telehealth services at any time
☐ The right to request an in-person visit instead of telehealth
☐ The right to access my medical records as provided by HIPAA (45 CFR § 164.524)
☐ The right to request amendments to my medical records (45 CFR § 164.526)
☐ The right to receive an accounting of disclosures (45 CFR § 164.528)
☐ The right to have my telehealth session conducted in a private manner
☐ The right to know who else may be present during the telehealth session
☐ The right to ask questions about the telehealth process

4.2 My Responsibilities

I agree to the following responsibilities:

☐ Provide accurate and complete health information
☐ Participate in a private location during telehealth sessions
☐ Ensure appropriate technology and internet connectivity
☐ Inform the provider if I do not understand any information provided
☐ Follow the treatment plan agreed upon with my provider
☐ Notify my provider if my condition worsens or I experience an emergency
☐ Maintain the confidentiality of any access codes or passwords provided
☐ Comply with all applicable laws regarding telehealth

SECTION 5: PRIVACY AND SECURITY

5.1 HIPAA Compliance

I understand that my healthcare provider is required to protect my health information in accordance with the Health Insurance Portability and Accountability Act (HIPAA):

• Privacy Rule (45 CFR Part 164 Subpart E): Protects the privacy of individually identifiable health information
• Security Rule (45 CFR Part 164 Subpart C): Establishes security standards for electronic protected health information (ePHI)
• Breach Notification Rule (45 CFR Part 164 Subpart D): Requires notification in case of a breach of unsecured PHI

5.2 Security Measures

My healthcare provider uses the following security measures to protect my information:

☐ End-to-end encryption of video and audio communications
☐ Secure, HIPAA-compliant telehealth platform
☐ Password protection and multi-factor authentication
☐ Automatic session timeout
☐ Secure storage of telehealth records
☐ Business Associate Agreements with technology vendors (per 45 CFR § 164.504(e))

5.3 Recording Policy

☐ Telehealth sessions will NOT be recorded without separate written consent
☐ Telehealth sessions MAY be recorded for the following purposes: [SPECIFY]
☐ If recording occurs, I will be notified and asked for consent before recording begins

SECTION 6: EMERGENCY PROTOCOLS

6.1 Emergency Situations

I understand that:

☐ Telehealth is NOT appropriate for emergency medical situations
☐ If I experience a medical emergency, I should call 911 or go to the nearest emergency room
☐ I should provide my physical location at the beginning of each telehealth session for emergency purposes

6.2 My Physical Location During Telehealth

State where I will be located during telehealth services: [STATE]

Physical address during telehealth session: [ADDRESS]

[// GUIDANCE: Documenting patient location is essential for emergency response and to ensure the provider is licensed in the state where the patient is located at the time of service.]

6.3 Emergency Contact

In case of emergency, I authorize my provider to contact:

Name: [EMERGENCY CONTACT NAME]
Relationship: [RELATIONSHIP]
Phone: [PHONE NUMBER]

SECTION 7: PRESCRIPTIONS AND REFERRALS

7.1 Prescribing Limitations

I understand that:

☐ Controlled substances may have additional prescribing requirements via telehealth under DEA regulations and state law
☐ Some medications may not be appropriate to prescribe without an in-person examination
☐ My provider will use professional judgment in determining appropriate prescriptions
☐ I must provide accurate information about my current medications and allergies

7.2 Referrals

☐ My provider may refer me to specialists or for in-person care when clinically indicated
☐ I may need to see a provider in person for certain procedures, tests, or examinations

SECTION 8: COSTS AND INSURANCE

8.1 Fees and Payment

☐ Telehealth services may be billed to my insurance, if covered
☐ I am responsible for any co-pays, deductibles, or non-covered services
☐ If services are not covered by insurance, I will be responsible for payment
☐ Self-pay rate for telehealth services: $[AMOUNT] per session

8.2 Insurance Coverage

☐ I have been informed that telehealth coverage varies by insurance plan and state
☐ I understand it is my responsibility to verify telehealth coverage with my insurance provider
☐ I authorize my provider to bill my insurance for telehealth services

[// GUIDANCE: As of 2025, 44 states plus DC have laws addressing private payer telehealth reimbursement, with 24 states having payment parity requirements. Verify your state's requirements.]

SECTION 9: ALTERNATIVE SERVICES

I understand that alternatives to telehealth are available, including:

☐ In-person office visits
☐ Telephone consultations (non-video)
☐ Referral to another healthcare provider
☐ Urgent care or emergency room visits for urgent matters
☐ No treatment (with understanding of associated risks)

I have been offered the option to receive services in person and have chosen to participate in telehealth services.

SECTION 10: STATE-SPECIFIC DISCLOSURES

[// GUIDANCE: Insert state-specific required disclosures here. Examples include:]

For California Patients (Cal. Bus. & Prof. Code § 2290.5):
☐ The healthcare provider has informed me of my right to receive a copy of my medical records
☐ My consent to telehealth will be documented in my medical record

For Texas Patients (Tex. Occ. Code § 111.005):
☐ I have been informed of my right to request an in-person visit
☐ I have been informed of the limitations of telehealth services

For Florida Patients:
☐ I have been informed that my provider is licensed in the State of Florida

[ADD ADDITIONAL STATE-SPECIFIC DISCLOSURES AS REQUIRED]

SECTION 11: PATIENT ACKNOWLEDGMENTS

By signing below, I acknowledge and agree to the following:

☐ I have read and understand this Telehealth Informed Consent form
☐ I have had the opportunity to ask questions and have received satisfactory answers
☐ I understand the benefits, risks, and limitations of telehealth services
☐ I understand that telehealth is voluntary and I may withdraw consent at any time
☐ I understand my rights and responsibilities as a telehealth patient
☐ I consent to the use of telehealth for my healthcare services
☐ I understand that I may request a copy of this consent form
☐ I verify that I am the patient or am authorized to consent on behalf of the patient
☐ I verify that I will be located in [STATE] during my telehealth sessions

SECTION 12: CONSENT

Patient Consent

I, the undersigned, hereby consent to participate in telehealth services with [PROVIDER NAME/PRACTICE NAME] for the purpose of receiving healthcare services.

Patient/Authorized Representative Signature: ______________________________________

Printed Name: [PATIENT/REPRESENTATIVE NAME]

Relationship to Patient (if applicable): [RELATIONSHIP]

Date: ______________

Time: ______________

Provider Acknowledgment

I have explained the nature, benefits, risks, and limitations of telehealth services to the patient/authorized representative. The patient/representative has had the opportunity to ask questions, and all questions have been answered to their satisfaction.

Provider Signature: ______________________________________

Provider Name: [PROVIDER NAME], [CREDENTIALS]

Date: ______________

VERBAL CONSENT DOCUMENTATION

(For states permitting verbal consent)

[// GUIDANCE: Some states (e.g., Texas, Kentucky) permit verbal consent with documentation. Use this section if verbal consent is obtained.]

☐ Verbal consent was obtained from the patient on [DATE] at [TIME]

Witness Name: [WITNESS NAME]

Witness Signature: ______________________________________

Date: ______________

Documentation of verbal consent placed in medical record: ☐ Yes

CONSENT WITHDRAWAL

I understand that I may withdraw my consent to telehealth services at any time by:

• Notifying my provider verbally during a telehealth session
• Submitting a written request to: [PRACTICE ADDRESS]
• Calling: [PRACTICE PHONE NUMBER]
• Emailing: [PRACTICE EMAIL]

Withdrawal of consent will not affect any services already provided.

This consent form is valid for [ONE YEAR / DURATION OF TREATMENT RELATIONSHIP / AS SPECIFIED] unless revoked by the patient.

[// GUIDANCE: Verify state requirements for consent duration and renewal. Some states require consent to be obtained only once before initial telehealth delivery; others may require periodic renewal.]