Telehealth Services Consent Form for Oncology Care

Patient Information

Name: _________________________ Date of Birth: _________________ Medical Record Number: _________

Consent for Telehealth Services

I, ______________________, hereby consent to participate in telehealth services with [Practice Name] for my oncology care. I understand that:

Nature of Telehealth Services

• Telehealth involves the use of electronic communications to enable healthcare providers to share individual patient medical information for diagnosis, therapy, follow-up, and/or education
• The telehealth consultation will be conducted through HIPAA-compliant video conferencing technology
• My oncologist will determine if telehealth is appropriate for my condition and care needs

Benefits & Limitations

• Telehealth allows for continuity of cancer care when in-person visits are not possible or necessary
• Physical examination capabilities are limited during virtual visits
• Some aspects of cancer care, including physical examinations and treatments, must be conducted in person

Privacy & Security

1. All existing confidentiality protections under federal and state law apply to telehealth services
2. Electronic systems used will incorporate network and software security protocols
3. No recordings of telehealth sessions will be made without separate written consent

Patient Rights & Responsibilities

I understand that:

• I have the right to withhold or withdraw this consent at any time
• I must be physically present in [State] during telehealth visits
• I must have reliable internet access and appropriate technology
• Emergency situations may require in-person evaluation

Signatures

Patient Signature: _________________ Date: _________

Provider Signature: ________________ Date: _________

Witness: _________________________ Date: _________