PERMISSION & AUTHORIZATION FORM
REGARDING THE USE OF TELEHEALTH SERVICES AND CONSULTATION
PLEASE READ BEFORE SIGNING:
Telehealth services involve the use of secure interactive encrypted videoconferencing equipment and devices that enable health professionals to deliver services to clients when located at different sites.
The telehealth consultation will be similar to a routine office visit, except interactive video technology will allow you to communicate with the provider at a distance. At first you may find it difficult or uncomfortable to communicate using video images. The use of video technology to deliver nutritional and educational services is a new technology and may not be equivalent to direct contact.
I understand that I will not be physically in the same room as my health professional.
I understand that there are potential risks to using technology, including service interruptions, interception, and technical difficulties. If it is determined that the videoconferencing equipment and/or connection is not adequate, I understand that my health professional or I may discontinue the telehealth visit and make other arrangements to continue the visit.
I understand that I have the right to refuse to participate or decide to stop participating in
a telehealth visit and that my refusal will be documented in my client record. I also understand
that my refusal does not constitute any refund and may limit my right to future care.
I understand that the laws that protect privacy and confidentiality of information apply to
telehealth services to the degree available.
I understand that my information may be shared with other qualified health professionals
and individuals for scheduling and billing purposes.
I understand that I will be responsible for any costs that apply to my telehealth visit.
I understand that payment policies for telehealth visits may be different from policies for
As with any procedure, there are potential risks associated with the use of telehealth.
These risks include, but may not be limited to:
- In rare cases, information transmitted may not be sufficient (e.g. poor resolution of
images) to allow for appropriate decision making.
- Delays in nutritional evaluation could occur due to deficiencies or failures of the
- In very rare instances, security protocols could fail, causing a breach of privacy of
- In rare cases, a lack of access to complete or accurate information may result in
adverse interactions or allergic reactions or other judgment errors.
By signing this form, I attest that I (1) have personally read this form (or had it explained
to me) and fully understand and agree to its contents; (2) have had my questions answered to my
satisfaction, and the limitations, benefits, and alternatives shared with me in a language I
understand; and (3) that this consent will remain active until I revoke it in writing.