Behavioral Health Telemedicine Consent

This form provides information about telemedicine services for behavioral health, and seeks your consent to participate in such services.

Telemedicine Overview

Telemedicine involves the use of electronic communications to enable healthcare providers to evaluate, diagnose, consult, and provide treatment.
All laws governing confidentiality and release of information apply to telemedicine.
You may withdraw your consent to participate in telemedicine at any time.

Telemedicine allows access to behavioral health care at a distance, but may be limited by technology failures.
There is a potential risk of unauthorized access due to the nature of electronic communication.
You may benefit from receiving behavioral health services without the need for travel.

I understand the information provided above and consent to participate in telemedicine for behavioral health.

I give my consent to participate in telemedicine behavioral health sessions.

Patient Name:

Date:

Patient Signature:

If patient is under 18, Parent/Guardian Name:

Parent/Guardian Signature:

Date: