YouthfulMD  - Informed Consent for Telehealth Visits

I hereby consent to receiving treatment through telehealth from my YouthfulMD  Medical clinician or a qualified member of the YouthfulMD  Medical care team. I understand that “telehealth” is the mode of delivering health care services and public health via information and communication technologies to facilitate the diagnosis, consultation, treatment, education, care management, and self-management of a patient’s health care. I understand that telehealth also involves the communication of my medical information, both orally and visually, to health care clinicians located at YouthfulMD  Medical affiliated facilities or elsewhere.

I understand that I have the following rights with respect to telehealth:

  1. I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment or risking the loss or withdrawal of any program benefits to which I would otherwise be entitled. I understand that receiving treatment through telehealth does not mean I cannot receive in-person health care services, either today or in the future. I understand that there are limitations to the types of treatment that can be appropriately provided via telehealth, and that my YouthfulMD  Medical clinician determines whether or not it is appropriate for me to receive treatment via telehealth.
  2. I understand that the information disclosed by me during the course of my treatment is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including but not limited to reporting child, elder, and depending adult abuse, expressed threats of violence towards an ascertainable victim, and where I make my mental or emotional state an issue in a legal proceeding. I also understand that the dissemination of any personally identifiable images from the telehealth interaction to other entities shall not occur without my written consent.
  3. I understand that I may benefit from telehealth, but that results cannot be guaranteed or assured. I also understand that there are risks involved in receiving treatment via telehealth, such as interruption of the audio-video connection or delays in receiving treatment because of technological failures.
  4. I understand that I have a right to access my health information and copies of medical records in accordance with state and federal law.
  5. I understand that I can discuss any questions that I have with my YouthfulMD  Medical clinician at the beginning of my telehealth consult, that my clinician will answer any such questions, and that I may decline to continue the telehealth consultation at any time.

By beginning my telehealth consult, I confirm that I have read and understand the information in this Informed Consent and that my name and identity have been correctly identified, and that I give my informed consent to receive treatment via telehealth from YouthfulMD Medical.