*Please provide your full legal name as it appears on your driver's license, state identification card, or government issued identification card.

Telehealth Informed Consent

* Required Information * Informaci�n requerida
This consent is for all telehealth services provided to me by PentaHealth:
Specifically, a health care professional will be communicating with me by electronic means, remotely via the Internet using a HIPAA compliant web-based audio-video software or telephone communication.
Telehealth may be for diagnosis, continuity of care, treatment, testing, or medical consultation deemed necessary by my Healthcare Provider or me.
I understand that during a Telehealth Appointment:
Details of my medical history and personal health information may be discussed with me and/or other health professionals.
There are benefits and limitations when compared to a traditional in-person visit because I will not be in the same room as my healthcare provider.
Either my Healthcare Provider or I can discontinue the Telehealth Appointment if either of us feels that the information obtained through remote communications is not adequate for diagnostic decision-making or for providing the care I desire.
The communication is privileged and confidential, and I will not record the audio or video.
Therefore, by consenting to this Telehealth Appointment:
I desire to engage in remote audio-visual communication with my Healthcare Provider.
I understand that my current insurance will be billed. I may be responsible for co-payments, deductibles, or other charges not covered by my insurance.
This consent will remain valid for 12 months from the date of this form.
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This form is meant to be submitted online. Please return to the form on your computer, answer all questions, and click the ‘Submit’ button when completed.