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BLUE VALLEY BEHAVIORAL HEALTH
Telehealth Patient Consent Form
Client Name:
Client Case #:
I agree to receive my outpatient behavioral health services through Telehealth. I understand that the
behavioral
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How to fill out telehealth consent
How to fill out telehealth consent
01
Start by downloading the telehealth consent form from the healthcare provider's website or obtain it in person.
02
Read the form carefully and ensure you understand all the information provided.
03
Provide your personal details such as name, date of birth, address, and contact information.
04
If applicable, include the name of your healthcare provider or the organization offering the telehealth services.
05
Review the terms and conditions section and indicate your agreement by signing and dating the form.
06
If you have any questions or concerns, reach out to your healthcare provider for clarification before signing.
07
Return the completed telehealth consent form to your healthcare provider via mail, email, or in person as instructed by them.
Who needs telehealth consent?
01
Anyone who is seeking or planning to access healthcare services through telehealth needs telehealth consent.
02
This may include patients, clients, or individuals who are going to receive medical advice, consultations, diagnoses, or treatments remotely.
03
In some cases, caregivers or legal guardians may also need to provide consent on behalf of patients, especially if they are minors or unable to consent themselves.
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What is telehealth consent?
Telehealth consent is obtaining permission or agreement from a patient to provide healthcare services through remote technology such as video conferencing or phone calls.
Who is required to file telehealth consent?
Healthcare providers and facilities offering telehealth services are required to obtain telehealth consent.
How to fill out telehealth consent?
Telehealth consent can be filled out by obtaining a patient's signature on a consent form or through electronic signatures.
What is the purpose of telehealth consent?
The purpose of telehealth consent is to ensure that patients understand the risks and benefits of receiving healthcare services remotely.
What information must be reported on telehealth consent?
Telehealth consent forms typically include information about the type of services being provided, potential risks, privacy policies, and patient rights.
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