Telehealth Consent
Telehealth Consent
LUXECARE MEDICAL
TELEHEALTH CONSENT FORM
Where Compassion Meets Excellence
1. PURPOSE OF TELEHEALTH
Telehealth involves the use of electronic communications (video, phone, or other digital methods) to provide medical care remotely to patients located in the state of Arizona.
2. NATURE OF SERVICES
- I understand my visit will be conducted via telehealth technology
- I understand the same standard of care applies as in-person visits
- I understand my provider may recommend in-person evaluation if needed
3. POTENTIAL BENEFITS
- Increased access to care
- Convenience and time savings
- Reduced need for travel
4. POTENTIAL RISKS
- Technical difficulties (poor connection, dropped calls)
- Limited ability to perform full physical exam
- Possible delay in diagnosis or treatment
5. CONFIDENTIALITY & PRIVACY
- I understand my information is protected under HIPAA and Arizona law
- I understand sessions are documented in my medical record
- I understand no recordings will occur without consent
6. PATIENT RESPONSIBILITIES
- I agree to provide accurate medical information
- I confirm I am physically located in Arizona during the visit
- I will be in a private and safe location
- I will provide my location and emergency contact
7. PRESCRIPTIONS & CONTROLLED SUBSTANCES
- I understand prescribing is subject to Arizona and federal law
- I understand some medications may require in-person evaluation
8. EMERGENCIES
- I understand telehealth is NOT for emergencies
- I will call 911 or go to ER if needed
9. ARIZONA TELEHEALTH ACKNOWLEDGMENT
- I confirm I am located in Arizona during this visit
- I understand Arizona law governs this care
- I understand provider must be licensed in Arizona
10. RIGHT TO WITHDRAW
- I understand I may withdraw consent at any time
11. CONSENT
- I have read and understand this form
- I had opportunity to ask questions
- I voluntarily consent to telehealth services
Patient Signature: _____ Date: _____
Provider Name: LuxeCare Medical
Provider Signature: _____ Date: _____
CONTACT INFORMATION
LuxeCare Medical
Arizona-specific telehealth consent form.