Informed Consent to Telehealth Services
IF YOU ARE EXPERIENCING AN EMERGENCY, DIAL 911 OR GO DIRECTLY TO THE NEAREST
HOSPITAL EMERGENCY ROOM.
Telehealth is healthcare provided by any means other than a face-to-face visit. In this telehealth visit,
you will be able to see and speak with your provider from remote locations.
I understand and agree that:
• I will not be in the same location or room as my medical provider. Telehealth services can only
be provided to me if, at the time of the telehealth service, I am residing in and located in the
state in which my provider has an office. I will report my location accurately during registration.
• Potential benefits of telehealth (which are not guaranteed or assured) include: (i) access to
medical care if I am unable to travel to my provider’s office; (ii) more efficient medical
evaluation and management; and (iii) during the COVID-19 pandemic, reduced exposure to
patients, medical staff and other individuals at a physical location.
• All electronic medical communications carry some level of risk. While the likelihood of risks
associated with the use of telehealth in a secure environment is reduced, the risks are
nonetheless real and important to understand. Potential risks of telehealth include: (i) limited
or no availability of diagnostic laboratory, x-ray, EKG, and other testing, and some prescriptions,
to assist my medical provider in diagnosis and treatment; (ii) my provider’s inability to conduct a
hands-on physical examination of me and my condition; and (iii) delays in evaluation and
treatment due to technical difficulties or interruptions, distortion of diagnostic images or
specimens resulting from electronic transmission issues, unauthorized access to my information,
or loss of information due to technical failures.
• I further understand that my provider’s advice, recommendations, or decisions may be based on
factors not within my provider’s control, including incomplete or inaccurate data provided by
me. I understand that my provider relies on information provided by me before and during our
telehealth encounter and that I must provide information about my medical history,
condition(s), and current or previous medical care that is complete and accurate to the best of
my ability.
• I understand that there are alternatives to telehealth, including in-office visits. I have the right to
receive face-to-face medical services at any time by traveling to my provider’s office during
office hours.
• I have the right to withdraw this consent to telehealth services or end the telehealth session at
any time without affecting my right to present or future treatment by my provider.
• I must take reasonable steps to protect myself from unauthorized use of my electronic
communications by others. I will not use an open, public Wi-Fi network for my telehealth visit.
• I understand that the level of care provided by my provider is to be the same level of care that is
available to me through an in-person medical visit but my provider makes no assurances or guarantees as to the results of treatment. If my
provider believes I would be better served by face-to-face services or another form of care, my provider can discontinue the telehealth
session and refer me for an in-office visit or to another appropriate health care provider or
hospital emergency department.
• I understand that telehealth billing information is collected in the same manner as a regular
office visit. My financial responsibility will be determined individually and governed by my
insurance carrier(s), Medicare, or Medicaid, and it is my responsibility to check with my
insurance plan to determine coverage.
• I understand that medical information, including medical records, are governed by federal and
state laws that apply to telehealth. This includes my right to access my own medical records
(and copies of medical records).
• I understand that electronic communication should never be used for emergency
communications or urgent requests. Emergency communications should be made to the
provider’s office or to the emergency 911 services.
By checking the “I agree” box below, I agree that I have reviewed this form, understand its content,
accept the risks and benefits of telehealth services, and consent to receive telehealth services.
If I am signing on behalf of a minor, incapacitated or otherwise legally dependent patient, I certify that I
am a person with legal authority to act on behalf of the patient, including the authority to consent to
medical services.
I agree to receive telehealth services.
I agree to receive SMS/text updates about my appointments and telehealth visits from Freeman
Family Medicine. Message frequency may vary. Message & data rates may apply. Reply STOP to opt out, HELP for help.
**List phone number authorized to receive text messages here _________________________**
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Patient Signature (Parent/Guardian Signature if patient is a minor)
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Printed Name