Tele-Health Patient Consent Form

Patient First Name *

Middle Initial

Patient Last Name *

Date of birth * +

Age *

Gender *

Male

Female

Street Address *

Address Line 2

City *

State *

Zip Code *

Parent / Guardian First Name *

Parent / Guardian Last Name *

What is the preferred number to reach you at? *

Phone Number *

Consent

CONSENT. I hereby consent to the use of telehealth by my Family Care Center provider. I understand that telehealth involves the communication of my health information, both orally and visually, with providers involved in my care who are located in a different location.

RISKS, BENEFITS AND ALTERNATIVES. I understand that I can expect benefits from telehealth, but no particular result can be guaranteed. The benefits of telehealth include having access to your provider without having to travel to Family Care Center. A potential risk of telehealth is that because of my specific medical condition, or due to technical problems, a face-to-face consultation still may be necessary after the telehealth appointment.

In the event that my telehealth session is interrupted, due to technical difficulties, the provider will attempt to contact me via phone. The evaluation of appropriateness of continuing with telehealth sessions will continue throughout my treatment including monitoring of symptoms and cooperativeness in assuming the responsibilities inherent in remote care. Additionally, in rare circumstances, security protocols could fail causing a breach of patient privacy. The alternative to a telehealth session is a face-to-face visit with my provider.

MEDICAL INFORMATION AND RECORDS. All laws concerning patient access to medical records and copies of medical records apply to telehealth. Dissemination of any patient identifiable images or information from the session to researchers or other entities shall not occur without my consent.

CONFIDENTIALITY. All existing confidentiality protections under federal and Colorado law apply to information used or disclosed during your telehealth session.

PATIENT CHOICE. I have the right to withhold or withdraw consent to a telehealth session at any time before and/or during the session without affecting my right to future care or treatment or risking the loss or withdrawal of any program benefits to which I would otherwise be entitled.

I have read the consent form and understand the Risks, Benefits and Alternatives, that my medical records will be maintained the same as if i were being see in the clinic, that my telehealth session is confidential, and that i have the right to discontinue telehealth sessions without affecting my right to care at Family Care Center. *

Yes

No

Please contact our offices and speak either with the admin or your provider to help answer any questions you may have. Thank you.

Patient Requirements

Family Care Center has confirmed that my insurance covers telehealth services. If not, I understand and agree to cover the full cost of payment for telehealth services. *

Agree

Disagree

I have a working email address and regular access to this email. *

Agree

Disagree

I have access to a high bandwidth internet connection capable of supporting audio and video without interruption or loss of quality. *

Agree

Disagree

I have access to a laptop or desktop computer or tablet with camera, microphone and speakers. Family Care center does NOT recommend the use of mobile devices for our telehealth sessions. *

Agree

Disagree

I will be in a safe and private, well lit, quiet and secure location at the time of consult. Coffee houses, buses, trains, cars, public areas with wi-fi and gyms are not considered acceptable locations to conduct a telehealth session. *

Agree

Disagree

I'm sorry you are not eligible for Telehealth, please email our intake department and asked to be scheduled with a provider who can see you in our office.

Safety Plan

Providing mental healthcare to patients using telehealth involves particular patient safety considerations. Family Care Center has safety plans in the event that the provider feels that safety is compromised during or after a session. In the event of an emergency, Family Care Center will talk with the patient or contact the local police department and/or the patient’s emergency contact.

Complete address at the time of session to include room, apartment and/or building number and zip code. *

Phone number you can be reached at if audio / video connection is lost: *

Emergency Contact #1 *

Emergency Contact #1 phone number *

Emergency Contact #2 *

Emergency Contact #2 phone number *

Law Enforcement Agency *

COS PD

Fountain PD

Monument PD

Manitou Springs PD

Ft Carson

El Paso Sheriff

Teller CO Sheriff *

Peterson AFB Security Forces

USAFA Security Forces

Other Law Enforcement Agency

Please sign below to acknowledge this consent. *

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