Diabetes Management Telehealth Consent

This consent form is for the use of telehealth services in the management of diabetes. Telehealth involves the use of electronic communications to enable health care providers to consult, diagnose, and treat patients remotely.

Nature of Telehealth

• Telehealth appointments may involve audio, video, and/or data communication.
• The laws that protect the privacy and confidentiality of medical information also apply to telehealth.
• Every reasonable effort will be made to ensure the security of medical information during telehealth sessions.

Possible Risks

• Risks include but are not limited to possible technical difficulties, interruptions, or unauthorized access.
• If the telehealth session cannot be conducted as planned, you may need to reschedule or attend an in-person visit.

Patient Rights

• You have the right to withhold or withdraw consent to telehealth at any time, without affecting your right to future care or treatment.
• All laws regarding the confidentiality of your health information apply to telehealth services.
• You have the right to ask questions about the telehealth procedures and discuss them with your provider.

Consent

By signing below, you acknowledge that you have read and understood the information provided above regarding telehealth for diabetes management, and you voluntarily consent to participate in telehealth services.