Hope & Faith Wellness Clinic - Telehealth Member Consent Form
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Patient Name: *
DOB: *
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Age: *
1. PURPOSE: The purpose of this form is to obtain your consent to participate in a telehealth consultation in
connection with HOPE & FAITH WELLNESS CLINIC PSYCHIATRIC SERVICES.

2. NATURE OF TELEHEALTH CONSULT: During the telehealth consultation: Details of your medical history,
examinations, x-rays, and test will be discussed with other health professionals through the use of
interactive video, audio, and telecommunication technology. b. A physical examination of you may take
place. c. A non-medical technician may be present in the telehealth studio to aid in the video
transmission. d. Video, audio and/or photo recordings may be taken of you during the procedure(s) or
service(s)

3. MEDICAL INFORMATION & RECORDS: All existing laws regarding your access to medical information and
copies of your medical records apply to this telehealth consultation. Please note, not all
telecommunications are recorded and stored. Additionally, dissemination of any patient- identifiable
images or information for this telehealth interaction to researchers or other entities shall not occur
without your consent.

4. CONFIDENTIALITY: Reasonable and appropriate efforts have been made to eliminate any confidentiality
risks associated with the telehealth consultation, and all existing confidentiality protections under federal
and Georgia state law apply to information disclosed during this telehealth consultation.

5. RIGHTS: You may withhold or withdraw consent to the telehealth consultation at any time without
affecting your right to future care or treatment or risking the loss or withdrawal of any program benefits
to which you would otherwise be entitled.

6. DISPUTES: You agree that any dispute arriving from the telehealth consult will be resolved in Georgia, and
that Georgia law shall apply to all disputes.

7. RISKS, CONSEQUENCES & BENEFITS: You have been advised of all the potential risks, consequences, and
benefits of telehealth. Your health care practitioner has discussed with you the information provided
above. You have had the opportunity to ask questions about the information presented on this form and
the telehealth consultation.

All your questions have been answered, and you understand the written information provided above.
I agree to participate in a telehealth consultation for the procedure(s) described above. *
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