Free Telehealth Consent Form Template
Telehealth Consent Form
Please complete this form to confirm your understanding and agreement.
Personal Information
Name
Date of Birth
Phone Number
Preferred Communication Method
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Phone Call
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Video Call
Insurance Information
Insurance Provider
Policy Number
Consent
By signing below, I confirm the following:
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I understand that telehealth involves the use of electronic communications to provide healthcare services remotely.
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I acknowledge that telehealth has limitations compared to in-person consultations, including the potential for technical issues.
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I agree to receive telehealth services from my healthcare provider and understand that I can withdraw consent at any time.
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I understand that my information will be protected under HIPAA and other applicable privacy laws, but there is a risk of unauthorized access due to the nature of electronic communication.
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I have had the opportunity to ask questions about telehealth and consent to proceed.
Name:
Date:
Consent Form Templates @ Template.net
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