Postpartum Telehealth Consent Form

This form is intended to obtain your consent for postpartum care delivered by telehealth. Telehealth allows you to receive care from your provider through electronic communication.

Key Points

• You understand what telehealth is and how it will be used for your postpartum care.
• You understand that telehealth has benefits and possible risks.
• Confidentiality and privacy will be maintained to the extent possible.
• You may withdraw your consent at any time.

Your Rights and Responsibilities

1. You may ask questions at any time.
2. You have the right to refuse telehealth visits and choose in-person visits where feasible.
3. You agree to provide accurate information to your provider.

Risks and Benefits

• Telehealth may reduce your travel time and increase your access to care.
• There may be limitations to assessment and treatment via telehealth.
• Technical failures could happen.

Confidentiality

• Your medical information will be kept confidential and protected by law.
• Electronic communication will be encrypted to the extent possible.

Consent

I have read and understand the information above and consent to receive postpartum care via telehealth.