Telehealth Services Consent

Please fill out the form below.

Patient Form B - Telehealth Services Consent

    1. Consent for Treatment: I consent to telehealth care performed by my provider and all associated healthcare workers at Family Medicine of SayeBrook. This includes examinations, treatment, and other health care services deemed medically necessary by the provider. I acknowledge that no guarantees have been made to me as to the result of any exam or treatment. I understand that I have the option to refuse the delivery of telehealth services at any time without affecting my right to future care or treatment.
    2. Consent forTelehealth Services: Telehealth involves transmissions of video and includes the exchange of protected health information pertinent to my care that includes but is not limited to test results, patient history, social history, medication management and other data deemed necessary for treatment.
      1. All confidentiality protections required by law or regulation will apply to my care.
      2. I have the right ta refuse or stop participation in telehealth services at any time and request an in-person appointment. I understand that in-persan services might not be available an the same day
    3. Records and Release of Information: The details of the Telehealth visits will become part of my medical records. Data will not be transmitted to people outside except as described below, and/or if I provide'written consent.
      1. I will have access to all the information in my medical record resulting from the telehealth services that I receive, as provided by federal and state law.
      2. The Providers may use or disclose my health information for treatment, continuity of care, payment, or internal operations or when required by law or regulation in certain unique situations.
      3. All releases of information are subject to the same laws and regulations as in person care.
    4. Payment Agreement/Assignment of Benefits: I agree to be responsible for any co-payments, deductibles, or other charges from the Providers and their providers that are not covered or paid by insurance except as prohibited by any state or federal law. I authorize Family Medicine of Saye Brook to file claim for payment and assign any benefits to Family Medicine of Saye Brook. It is my responsibility to know what providers and telehealth services are covered under my insurance plan. I understand that I may be billed for and agree to pay for my portion of telehealth services billed by Family Medicine of SayeBrook

    By signing this form, I acknowledge that I have read this information and agree to treatment by telehealth.

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  • You agree that typing your electronic signature is the legal equivalent of your manual signature on this form.
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