Free Telehealth Release Form Template
Telehealth Release Form
Please provide the required information below.
Patient Information
Name
Date of Birth
Phone number
Medical Information
Diagnosis
What has the patient been diagnosed with?
Symptoms
What are symptoms the patient experienced?
Is the patient currently experiencing any symptoms?
Comments
Is the patient recovered enough to be released?
Date and Time of Release
Terms and Conditions
By signing this form, I consent to the secure exchange of my medical information regarding my treatment through telehealth services. All information shared during these sessions will be kept confidential and protected under HIPAA and other applicable privacy laws.
I acknowledge that I have received the necessary telehealth services and consent to being released from further telehealth treatment. I understand that any ongoing medical needs may require follow-up care or in-person visits.
I confirm that I have discussed my treatment plan and have received the necessary care through telehealth. I acknowledge that I have been informed about my condition and any follow-up care required.
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Patient
Name: Date: |
Doctor
Name: Date: |
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