Out-of-State Telehealth Informed Consent

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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:

Patient's First and Last Name

Patient's Date of Birth

Provider's Name (Dr. Lewiecki, Dr. Rudolph, Desiree)

Date of Appointment

My healthcare provider is not at liberty to treat my condition for telehealth visits (where applicable). I am limited to a consultation and recommendations only.
I understand that telehealth involved sharing my health information electronically. I will tell my healthcare provider if there is any information that I do not want to talk about in a telehealth visit.
I understand that I may stop the telehealth visits at any time. If I decide to stop, I will still be able to receive care at this office.
I understand that I may have to check with my insurance plan to see if telehealth visits are covered.
I agree that information shared during my telehealth visit will be kept by the healthcare providers and facilities involved in my care.
I understand that the telehealth visit may or may not be recorded.
I understand that I will be asked to confirm my identity and current location to the healthcare provider seeing me.
I also have the right to confirm the identity and credentials of the healthcare provider who will be seeing me.
I understand that telehealth visits carry a certain level of risk. These risks include, but are not limited to:

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.

My signature below denotes my understanding of all information on this form. Any questions I had have been answered and I wish to proceed with a telehealth visit.

Clear Signature

Patient or Legal Representative Signature

Print Patient's or Legal Representative's Name

Legal Representative's Relationship to Patient

Today's Date

Out-of-State Telehealth Informed Consent

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:

Clinical Research

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Patient Information

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Medical Practice

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