Out-of-State Telehealth Informed Consent

Please enable JavaScript in your browser to complete this form.

Telehealth (also called telemedicine) is a way to visit with your healthcare provider without going to a hospital or clinic. The visits are held by computer, tablet, or telephone.

This form gives permission for telehealth communication between the following parties:

  • My computer, tablet, or phone may not be private and secure, especially if other people use it. It is my responsibility to make sure my internet system is private and secure and to make sure I am in a private place during the visit.
  • Technical problems may interrupt or stop the visit before it is done.
  • My healthcare provider cannot examine me as closely during a telehealth visit, and this may make it harder to determine what is wrong with me.