Telehealth Consent Form

Last Modified: July 18, 2022

“Telehealth” is the delivery of health care services using audio and video communication technologies and the electronic exchange of information. In using the Ohla Medical services, you will be consulting with a licensed clinician (“Provider”) solely via the use of Telehealth. Since this is different than in-person health care services you may typically receive, it is important for you to understand and be aware of and comfortable with the benefits and possible risks.

Some possible risks associated with the use of Telehealth services include, but may not be limited to:

The electronic information sent to your Provider may not be sufficient for the Provider to make an appropriate medical decision.
Equipment issues, which could cause delays in your medical evaluation and treatment.
Although rare, security measures could fail, possibly exposing your privacy and your personal medical information.
Finally, in some cases, Telehealth services may not be as complete as in-person services, and if your provider believes an in-person visit is necessary, he or she may recommend that you schedule an in-person visit.

By acknowledging my consent, I understand and agree to the following:

I understand that Ohla Medical and the Provider offer Telehealth consultations, which are conducted through videoconferencing, telephonic, and asynchronous technology and my Telehealth provider will not be present in the room with me.
I understand there are potential risks to the use of Telehealth technology, including but not limited to, interruptions, delays, unauthorized access, and or other technical difficulties. I understand that either my Telehealth provider or I can discontinue the Telehealth appointment if the technical connections are not adequate for my visit.
I understand that I could seek an in-office visit rather than obtain care from a Telehealth provider, and I am choosing to participate in a Telehealth consultation with Ohla Medical and the Provider.
To protect the confidentiality of my health information, I agree to undertake my Telehealth consultation in a private location, and I understand that my Telehealth provider will similarly be in a private location.
I understand that I have a duty to answer questions about my health and medical history honestly and accurately, and to keep all of my health care providers, including my Provider, up-to-date on any changes in my health, symptoms, treatments, or medications.
I understand that I am responsible for payment of any amounts due and owing resulting from my Telehealth visit.
In an emergent situation, I understand that the responsibility of my Telehealth provider may be to direct me to emergency medical services, such as an emergency room.

By acknowledging my consent, I certify:

that I have read this form and/or had it explained to me
that I understand the risks and benefits of a Telehealth appointment
that I have been given the opportunity to ask questions and that such questions have been answered to my satisfaction.