TELEMEDICINE PATIENT CONSENT FORM
- I hereby authorize G&H Healthcare to use the telehealth practice platform for telecommunication for evaluating, testing, and diagnosing my medical condition.
- I understand that technical difficulties may occur before or during my telehealth session and my appointment may not be started or ended as intended.
- I accept that the professionals can contact interactive session with video call; however, I am informed that the sessions can be conducted via regular voice communication if the technical requirements such as internet speed cannot be met.
- I understand that my current insurance may not cover the additional fees of the telehealth practices and I may be responsible for any fee that my insurance company does not cover
- I agree that my medical records on telehealth can be kept for further evaluation, analysis and documentation, and in all of these, my information will be kept private under HIPAA law.
- I understand I may withhold or withdraw consent to the telemedicine consultation at any time without affecting my right to future care of treatment.
- I hereby fully and voluntarily consent, for myself or on behalf of the patient on whose behalf I am seeking treatment, as applicable, to participation in a virtual visit, and attest that I (1) have personally read this form (or had it explained to me) and fully understand and agree to its contents; (2) have had the opportunity to ask questions, and have had my questions answered to my satisfaction, and the risks, benefits, and alternatives to virtual medicine visits shared with me in a language I understand; and (3) I am located in the State of Oregon and will remain in the State Oregon for the duration of my virtual visit.
I agree to participate in a telemedicine consultation as described above.
Signature: _____________________________________________ Date: ________________