Telehealth Services Consent Form for Geriatric Care

Patient Information

Name: _________________________ Date of Birth: _________________ Address: _______________________ Phone: _______________________

Nature of Telehealth Services

I understand that telehealth involves the delivery of healthcare services using electronic communications, information technology, or other means between a healthcare provider and a patient who are not in the same physical location.

Consent and Understanding

By signing this form, I understand and agree to the following:

1. Technology Requirements

   • I need access to reliable internet connection
   • I must have a device with video and audio capabilities
   • I am responsible for ensuring privacy at my location

2. Medical Information and Records

   • Electronic systems used will incorporate network and software security protocols
   • All existing laws regarding medical information access will apply
   • All confidentiality protections under HIPAA apply

3. Benefits and Risks

   • Benefits include improved access to care and convenience
   • Risks include potential technical difficulties and limited physical examination
   • In case of emergency, I understand I should call 911

4. Patient Rights

   • I can withhold or withdraw my consent at any time
   • I have the right to inspect all information obtained during telehealth interactions
   • I may expect the anticipated benefits from telehealth, but results cannot be guaranteed

Signatures

Patient Signature: _________________ Date: _________________

Witness Signature: _________________ Date: _________________

Healthcare Provider: _________________ Date: _________________