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WWW.apexcounselingservices.com PH: (614) 7511090FAX: (614) 7511091TELEHEALTH INFORMED CONSENT I name of patient hereby consent to engaging in telehealth at Apex Counseling Services, LLC (ACS) as part

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How to fill out telehealth consent form

01

Start by providing your personal information such as name, address, contact details, and date of birth.

02

Read and understand the terms and conditions mentioned in the telehealth consent form.

03

Sign and date the form to indicate your agreement and understanding of the consent.

04

If necessary, provide any additional information or medical history that may be relevant for the telehealth consultation.

05

Submit the completed form to the healthcare provider or telehealth platform as instructed.

Who needs telehealth consent form?

01

Anyone who wishes to receive medical or healthcare services through telehealth needs to fill out a telehealth consent form.

02

This form ensures that the individual understands and agrees to the terms and conditions of receiving healthcare services remotely.

03

It is especially relevant for patients who are seeking remote medical consultations, prescriptions, follow-up appointments, or any other type of telemedicine service.

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What is telehealth consent form?

Telehealth consent form is a document that allows a patient to give permission to receive medical services via telecommunication technologies.

Who is required to file telehealth consent form?

Patients who wish to receive medical services through telehealth are required to fill out a telehealth consent form.

How to fill out telehealth consent form?

To fill out a telehealth consent form, patients need to provide their personal information, agree to terms and conditions, and sign the document.

What is the purpose of telehealth consent form?

The purpose of telehealth consent form is to ensure that patients understand and agree to receive medical services remotely.

What information must be reported on telehealth consent form?

Information such as patient's name, contact details, medical history, and consent to telehealth services must be reported on the telehealth consent form.

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