HealthFirst Telehealth Consent Form

Telehealth Informed Consent

Telehealth involves the delivery of healthcare services using electronic communications, information technology, or other means between a healthcare provider and a patient who are not in the same physical location.

By participating in telehealth services with HealthFirst Telehealth, I understand and agree to the following:

Nature of Telehealth

Telehealth services may include, but are not limited to:

• Live two-way video or audio communication

• Review of medical records, laboratory results, and images

• Electronic transmission of medical information

I understand that telehealth does not replace the need for in-person care when clinically necessary.

Benefits

Potential benefits of telehealth include:

• Convenient access to care

• Reduced travel time and costs

• Timely medical consultation

Risks and Limitations

I understand that:

• Technical difficulties may interfere with communication

• The provider may be unable to conduct a full physical exam

• Diagnosis and treatment decisions may be limited by the information available

• There is a small risk of unauthorized access despite security safeguards

Confidentiality

All telehealth communications are conducted using HIPAA-compliant platforms. My medical information will be protected according to applicable state and federal privacy laws. However, no electronic system is completely secure.

Emergency Situations

Telehealth services are not appropriate for medical emergencies.

If I am experiencing a medical emergency, I agree to call 911 or go to the nearest emergency department.

Right to Withdraw

I understand that I may withdraw my consent for telehealth services at any time by notifying HealthFirst Telehealth in writing.

Consent

By agreeing below, I acknowledge that:

• I have read and understand this Telehealth Informed Consent

• I have had the opportunity to ask questions

• I voluntarily consent to receive telehealth services from HealthFirst Telehealth