Telemedicine Consent and Insurance Form

Personal Information

Full Name Date of Birth Phone Number Email Address Address

Insurance Information

Insurance Provider Insurance ID Number Group Number Subscriber Name

Telemedicine Consent

I understand that telemedicine involves the use of electronic communications to enable health care providers to share medical information for the purpose of improving patient care. I understand that I have the following rights:

• Confidentiality of my health information
• To withdraw my consent at any time

I have read and agree to the Telemedicine Consent

Signature

Patient/Guardian Signature Date