Telemedicine Patient Confidentiality Agreement

This agreement is entered into between:

Patient Name: Date of Birth: Provider Name:

The purpose of this agreement is to ensure the confidentiality of all medical information shared via telemedicine services.

Confidentiality Terms

• All personal health information shared during telemedicine consultations is confidential and protected by applicable laws and regulations.
• The provider agrees to maintain the privacy and security of the patient’s information.
• The patient agrees not to record, copy, or distribute any part of the telemedicine consultation without consent.
• Both parties acknowledge the use of secured platforms for telemedicine sessions.

Patient Acknowledgement

I acknowledge that I have read and understood the confidentiality terms regarding the use of telemedicine services. I agree to adhere to these terms.

Patient Signature: Date: