Consent for Telehealth Services. Telehealth involves transmission of video, photographs, and/or details of my medical record such as x-rays and test results (collectively, “Data”). I understand that: • I will be informed of any other people who are present at the Providers’ end of the telehealth encounter, and have the right to exclude anyone. • Except as modified or waived by Executive Order or other action taken by Federal or State authorities, all confidentiality protections required by law or regulation will apply to my care. • I have the right to refuse or stop participation in telehealth services at any time and request alternate services such as an in-person appointment. However, I understand that equivalent in-person services might not be available at the same location or time as telehealth services. • If I do not want to receive health care services by telehealth, it will not affect my right to future care or treatment, or any insurance/ program benefits to which I would otherwise be entitled. • If an emergency occurs during a telehealth encounter at a hospital or clinic, health care personnel at my location will manage the emergency. If an emergency occurs during a telehealth encounter when I am at a non-health-care site, I should call 911 and stay on the video connection (if applicable) until help arrives.
Consent for Telehealth Services. Although signing the Consent for Telehealth Services acknowledgment is required, it does not in any way obligate you to receive services via Telehealth delivery.
Consent for Telehealth Services. If Telehealth Services are deemed necessary by myself and Twin State Psychological Services staff, I agree and give my informed consent to the following:
Consent for Telehealth Services. Telehealth involves transmission of video, photographs, and/or details of my medical record such as x-rays and test results (collectively, “Data”). All Data is sent by secure electronic means to the Providers to facilitate the medical service being performed. I understand that: I will be informed of any other people who are present at either end of the telehealth encounter and have the right to exclude anyone from either location. All confidentiality protections required by law or regulation will apply to my care. I have the right to refuse or stop participation in telehealth services at any time and request alternate services such as an in-person appointment. However, I understand that equivalent in-person services might not be available at the same location or time as telehealth services. If I do not want to receive health care services by telehealth, it will not affect my right to future care or treatment, or any insurance/ program benefits to which I would otherwise be entitled.
Consent for Telehealth Services. The Telehealth Services may be used for diagnosis, treatment, care, and follow-up, providing information about patient laboratory test results and for patient education, and may include, but is not limited to:
