Telehealth Consent Telehealth Consent PentaHealth Telehealth Informed Consent(Required)This consent is for all telehealth services provided to me by PentaHealth: Specifically, a health care professional will be communicating with me by electronic means, remotely via the internet using a HIPAA compliant web-based audio-video software or telephone communication. Telehealth may be for diagnosis, continuity of care, treatment, testing, or medical consultation deemed necessary by my healthcare provider or me. I understand that during a telehealth appointment: • Details of my medical history and personal health information may be discussed with me and/or other health professionals. • There are benefits and limitations when compared to a traditional in-person visit because I will not be in the same room as my healthcare provider. • Either my healthcare provider or I can discontinue the telehealth appointment if either of us feels that the information obtained through remote communications is not adequate for diagnostic decision-making or for providing the care I desire. • The communication is privileged and confidential, and I will not record the audio or video. Therefore, by consenting to this telehealth appointment: • I desire to engage in remote audio-visual communication with my healthcare provider. • I understand that my current insurance will be billed. I may be responsible for co-payments, deductibles, or other charges not covered by my insurance. By checking the box for this “TELEHEALTH INFORMED CONSENT,” I hereby confirm that I am a resident of Pennsylvania and have read, understood, and agree to the terms of this document.Name(Required) First Last Phone(Required)Date of Birth(Required) MM slash DD slash YYYY Email Signature(Required)Today's Date(Required) MM slash DD slash YYYY Δ
