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Family Therapy Center of Madison, Inc. 700 Radovan Drive, Suite 220 Madison, WI 53711 CONSENT FOR TELEHEALTH SERVICES AND TREATMENT (Please print, sign and return to the address above) To our patients
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How to fill out consent for telehealth services

01
Fill out your personal information, such as name, address, and contact details.
02
Read the telehealth service provider's terms and conditions and privacy policy.
03
Provide your medical history, including any chronic conditions or allergies.
04
Understand and agree to the telehealth service's payment method and fees.
05
Review and sign the consent form, indicating your understanding and agreement to receive telehealth services.
06
Submit the completed consent form to the telehealth service provider either electronically or by fax or mail.

Who needs consent for telehealth services?

01
Anyone seeking to receive telehealth services
02
Individuals who are unable to physically visit healthcare facilities
03
Patients who prefer the convenience of remote healthcare consultations
04
People in remote or rural areas with limited access to traditional healthcare services
05
Individuals with mobility or transportation limitations
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Consent for telehealth services is the permission given by a patient to allow healthcare providers to deliver care remotely using technology.
Patients are required to file consent for telehealth services before receiving remote healthcare.
Patients can fill out consent for telehealth services by signing a form provided by their healthcare provider or clicking on an electronic agreement.
The purpose of consent for telehealth services is to ensure that patients understand and agree to receive healthcare remotely using technology.
Consent for telehealth services must include details about the patient's agreement to receive remote care, the type of telehealth services offered, and any limitations or risks involved.
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