I, the undersigned patient, hereby authorize the release, disclosure, and use of my protected health information (PHI) as described in this authorization.

Purpose: To facilitate telehealth consultation, treatment coordination, and continuity of care with the treating provider and their clinical team.

Information to be disclosed: Medical records, laboratory results, imaging reports, medication lists, and any other clinical information relevant to my current or ongoing care.

Duration: This authorization is valid for one (1) year from the date of signature, unless revoked earlier in writing.

Right to revoke: I understand that I have the right to revoke this authorization at any time by submitting a written request. Revocation will not affect any actions already taken in reliance on this authorization.

Voluntary: I understand that signing this authorization is voluntary. My treatment will not be conditioned upon signing, except where the information is necessary for treatment.

I understand that information disclosed under this authorization may be subject to re-disclosure and may no longer be protected by federal privacy regulations.

I understand that telehealth involves the delivery of healthcare services using electronic communications, information technology, or other means between a healthcare provider and a patient who are not in the same physical location.

Benefits: Improved access to care, convenience, and reduced travel time. The ability to receive care from a specialist who may not be available locally.

Risks: Information transmitted may not be sufficient (e.g., poor resolution of images) to allow for appropriate medical decision-making. Delays in evaluation or treatment may occur due to technology failures. Security protocols could fail, causing a breach of privacy.

Alternatives: I understand that alternatives to telehealth include traditional in-person visits. I may choose to pursue in-person care at any time.

Rights: I may withdraw my consent to participate in telehealth services at any time without affecting my right to future care or treatment. I have the right to inspect all medical information transmitted during a telehealth interaction.

By signing below, I acknowledge that I have read and understand this consent, and I voluntarily agree to receive telehealth services.