Telehealth Consent

T E L E H E A L T H C O N S E N T

TELEHEALTH INFORMED CONSENT FORM

Please read the following statement, check boxes #1-#6 to acknowledge your rights, & type your name to complete the Telehealth Informed Consent Form.

* Indicates required field

I, being physically located in Virginia, hereby consent to engaging in telehealth with Chesapeake Care Clinic as part of my medical treatment. I understand “telehealth” means the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, & education using interactive audio, video, or data communications. I understand telehealth involves the communication of my medical information both orally & visually to a health care provider at Chesapeake Care Clinic located in Virginia. *

By checking each of the following, I understand I have these rights with respect to telehealth:

#1 *

I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment nor risking the loss or withdrawal of any program benefits to which I would otherwise be entitled.

#2 *

The laws that protect the confidentiality of my medical information also apply to telehealth. I understand the audiovisual information transmitted electronically will be encrypted during transmit & will not be stored. I also understand the dissemination of any personally identifiable images or information from the telehealth interaction to researchers or other entities shall not occur without my consent. I understand the information disclosed by me during the course of my therapy is generally confidential. However, there are both mandatory & permissive exceptions to confidentiality, including, but not limited to reporting child, elder, & dependent adult abuse; expressed threats of violence towards an ascertainable victim; & where I make my mental or emotional state an issue in a legal proceeding.

#3 *

I understand there are benefits, risks & alternatives involved with telehealth. Benefits include having access to medical care without having to travel outside of my local community. A potential risk of telehealth is because of my specific medical conditions, or due to technical problems, a face-to-face consultation still may be necessary after the telehealth appointment. Despite reasonable efforts on the part of my physician, the transmission of my medical information could be disrupted or distorted by technical failures. In rare circumstances, security protocols could fail causing a breach of patient privacy.

#4 *

I understand telehealth based services & care may not be as complete as face-to-face services. I also understand if my physician believes I would be better served by another form of services (for example face-to-face services) I will be referred to a physician who can provide such services in my area.

#5 *

I understand I may benefit from telehealth, but the results cannot be guaranteed or assured.

#6 *

I understand I have a right to access my medical information & copies of my medical records in accordance with Virginia law.

By typing my name, I certify that I have read & understand the information provided. I have discussed any questions I might have with Chesapeake Care Clinic designated staff, & all of my questions have been answered to my satisfaction. *

Date of Birth (mm/dd/yyyy) *

Phone Number for Telehealth Appointments *

Submit

T E L E H E A L T H C O N S E N T

​TELEHEALTH INFORMED CONSENT FORM

TELEHEALTH INFORMED CONSENT FORM