TELEMEDICINE INFORMED CONSENT AND AGREEMENT
THIS TELEMEDICINE INFORMED CONSENT AND AGREEMENT ("Agreement") is made as of [Date],
BETWEEN:
[Healthcare Provider/Practice Name], located at [Address] ("Provider"),
AND:
[Patient Name], date of birth [DOB], located at [Address] ("Patient").
1. PURPOSE AND NATURE OF TELEMEDICINE
1.1 Definition. Telemedicine involves the delivery of healthcare services using electronic communications, including video conferencing, telephone, secure messaging, and remote monitoring technologies, when the Patient and Provider are not in the same physical location.
1.2 Purpose. This Agreement documents Patient's informed consent to receive healthcare services via telemedicine technology and establishes the terms of the telemedicine relationship.
1.3 Services. Telemedicine services may include: (a) medical consultations and evaluations; (b) diagnosis and treatment recommendations; (c) prescription of medications (where clinically appropriate and legally permitted); (d) review of medical records, images, and test results; (e) follow-up care and monitoring; (f) mental health counseling and therapy; (g) health education and wellness coaching.
2. TECHNOLOGY REQUIREMENTS AND LIMITATIONS
2.1 Equipment. Patient shall provide: (a) a device with camera and microphone capabilities; (b) reliable internet connection (minimum [5] Mbps); (c) a private, quiet location for consultations.
2.2 Technology Limitations. Patient acknowledges that: (a) technical difficulties may interrupt or prevent telemedicine sessions; (b) electronic communications may fail due to hardware, software, or connectivity issues; (c) audio/video quality may be affected by bandwidth limitations; (d) security measures cannot guarantee absolute protection against unauthorized access.
2.3 Not a Substitute. Telemedicine is not appropriate for all medical conditions. Patient understands that some conditions require in-person examination, diagnostic testing, or emergency care that cannot be provided via telemedicine.
3. PATIENT RIGHTS
3.1 Patient has the right to: (a) withhold or withdraw consent to telemedicine at any time without affecting the right to future care; (b) request an in-person visit instead of telemedicine; (c) access medical records generated during telemedicine visits; (d) receive information about Provider's qualifications and licensing; (e) expect the same standard of care as in-person visits; (f) a private consultation without unauthorized persons present.
3.2 Second Opinion. Patient may seek a second opinion at any time.
4. PATIENT RESPONSIBILITIES
4.1 Patient agrees to: (a) provide accurate and complete medical history, symptoms, and information; (b) inform Provider of all medications, supplements, and allergies; (c) follow treatment plans and medication instructions; (d) keep scheduled appointments or provide [24] hours notice for cancellation; (e) contact emergency services (911) for medical emergencies; (f) be in a state where Provider is licensed to practice at the time of consultation.
4.2 Identity Verification. Patient shall verify identity as requested by Provider at the start of each session.
5. PRIVACY AND SECURITY
5.1 HIPAA Compliance. Provider shall maintain the privacy and security of Patient's protected health information (PHI) in accordance with the Health Insurance Portability and Accountability Act (HIPAA) and applicable state laws.
5.2 Encryption. All telemedicine sessions shall use HIPAA-compliant, encrypted communication platforms. Provider currently uses [Platform Name].
5.3 Recording. Telemedicine sessions [will/will not] be recorded. If recorded, recordings are maintained as part of the medical record and subject to the same privacy protections.
5.4 Third Parties. Provider shall inform Patient if any other healthcare professionals, students, or trainees will be present during the session. Patient may object to their participation.
6. PRESCRIPTIONS
6.1 Provider may prescribe medications via telemedicine when clinically appropriate and permitted by applicable law.
6.2 Provider may decline to prescribe certain medications (including controlled substances) via telemedicine based on clinical judgment or regulatory requirements.
6.3 Prescriptions will be sent electronically to Patient's designated pharmacy: [Pharmacy Name and Address].
7. FEES AND BILLING
7.1 Fees. Telemedicine visits are billed at: $[Amount] per visit / at the same rate as in-person visits.
7.2 Insurance. Patient is responsible for verifying telemedicine coverage with their insurance provider. Provider will submit claims to [Insurance Company] if applicable.
7.3 Co-Pays. Patient is responsible for applicable co-pays, deductibles, and coinsurance, payable at the time of service.
7.4 Cancellation Fee. Appointments cancelled with less than [24] hours notice or missed appointments may incur a fee of $[Amount].
8. EMERGENCY PROTOCOLS
8.1 Patient understands that telemedicine is NOT for emergencies. In case of emergency, Patient shall call 911 or go to the nearest emergency room.
8.2 Patient shall provide Provider with: (a) current physical location during each session; (b) name and phone number of local emergency contact; (c) nearest emergency facility information.
9. RISKS AND BENEFITS
9.1 Benefits may include: improved access to care, reduced travel, convenience, timely consultations, and access to specialists.
9.2 Risks may include: technology failures, limited physical examination capability, potential misdiagnosis without in-person assessment, privacy risks inherent in electronic communication, and delays in treatment if technology fails.
10. INFORMED CONSENT
10.1 By signing below, Patient acknowledges: (a) having read and understood this Agreement; (b) having had the opportunity to ask questions; (c) voluntarily consenting to telemedicine services; (d) understanding the risks, benefits, and limitations described herein.
11. GOVERNING LAW
11.1 This Agreement shall be governed by and construed in accordance with the laws of the State of [State/Jurisdiction].
11.2 Disputes shall be resolved in the courts of [County], [State].
12. SEVERABILITY
12.1 If any provision is held invalid, the remaining provisions continue in full force.
13. ENTIRE AGREEMENT
13.1 This constitutes the entire agreement between the Parties. No amendment is valid unless in writing signed by both Parties.
14. NOTICES
14.1 All notices shall be in writing, delivered by certified mail or overnight courier to the addresses above.
DISCLAIMER: This template is for informational purposes only and does not constitute legal advice. Consult qualified legal counsel.
SIGNATURES
[PARTY A]:
Signature: _________________________ Name: [Full Name] Title: [Title] Date: __________
[PARTY B]:
Signature: _________________________ Name: [Full Name] Title: [Title] Date: __________
