Consent for Telehealth Visits
What is telehealth?
Telehealth is a way to visit with healthcare providers (“Provider”), such as your doctor or nurse practitioner, by using electronic communications to enable your Providers to care for you without an in-person office visit. Providers may include primary care practitioners, mental health providers, specialists and/or subspecialists, nurse practitioners, registered nurses, medical assistants, and other healthcare providers who are part of Equal Health’s clinical care team.
How do I use telehealth?
During your appointment you will speak with your Provider through your Athena Health patient portal using your own electronic device (phone, computer, or tablet).
Before you begin your appointment, please set up your device in a private and stationary location. Do not use a public wireless network to connect for your visit. For your safety, do not drive or operate heavy machinery during your appointment, and please arrive at least 10 minutes ahead of your scheduled appointment time.
How does telehealth help me?
Telehealth provides healthcare services to you without having to travel to your Providers office and may provide you with care that might otherwise be difficult for you to obtain due to distance, scheduling difficulty, disability, or illness.
Can telehealth be bad for me?
You and your Provider won’t be in the same room, so it may feel different than an office visit. It can be difficult for your Provider to examine you as closely as they might during a physical office visit and that could potentially result in a mistake. Even after your telehealth visit, you Provider may decide that you need to be seen in person by a Provider. In addition, telehealth requires that you have access to a compatible electronic device and reliable internet connection.
Will my telehealth visit be private?
What if I try telehealth and don’t like it?
You can stop using telehealth any time, even during a telehealth visit. Notify your Provider immediately if you wish to stop your visit.
Equal Health provides exclusively telehealth-based services. Please note, if you withdraw your consent to receive telehealth services, you will need to notify Equal Health to cancel your subscription.
How much does a telehealth visit cost?
Equal Health does not currently accept health insurance. What you pay depends on the subscription and membership level you have.
Do I have to sign this document?
You should sign this document only if you would like to use telehealth services, understand the contents of this document, and agree with all the terms.
What if I have other questions?
If you have additional questions please email Equal Health at firstname.lastname@example.org before you sign this document.
What does it mean if I sign this document?
If you sign this document, you agree to the statement below and wish to receive telehealth services from Equal Health.
By agreeing to use the telehealth services, I hereby agree to the following statements and terms:
I have read Equal Health’s Privacy Policies and have fully reviewed their contents.
I understand, agree, and expressly consent to Equal Health obtaining, using, storing, and disseminating to necessary third parties, information about me, including my image, as necessary to provide the telehealth services.
I understand that my Provider will communicate with me using my Athena Health patient portal, and that I am required to maintain an account with Athena Health, a third-party, to receive telehealth services from Equal Health.
I hereby release and hold harmless Equal Health and all members of my care team from any loss of data or information due to technical failures associated with the telehealth services.
I understand and agree that the health information I provide at the time of my telehealth service may be the only source of health information used by the medical professionals during my evaluation and treatment during my telehealth visit, and that it is my responsibility to provide accurate information to my Provider during my appointment.
I understand that I will be given information about test(s), treatments(s) and procedures(s), as applicable, including the benefits, risks, possible problems or complications, and alternate choices for my medical care through the telehealth visit.
I understand that I have the right to discuss all medical treatments with my Provider.
I understand that I have the right to withhold or withdraw consent to the use of telehealth services at any time.
I understand the risks associated with obtaining medical treatment via telehealth.
I have carefully read and understand the above statements.
I understand that this informed consent will become a part of my medical record.
All my questions have been answered to my satisfaction.
By signing below, I certify that I am the legal representative of the participant or that I am the patient and am 18 years of age or older, or otherwise legally authorized to consent.