Patient Informed Consent for Telehealth Services



What is telehealth and why would I want to use it? Telehealth uses electronic communication to provide care from a distance (from where you are located) and at the time you need care. It uses equipment that can stream live health care visits similar to “FaceTime”. Streaming often occurs through a patient portal that shows your care team on a screen. A patient portal can also be used for written communication with your care team, which is another type of telehealth. Telehealth can be used to assess your weight, blood pressure and other types of monitoring.

How can telehealth help me? Your care team can use telehealth to examine, consult, diagnose and treat you. Telehealth can also be used to provide education, help you manage your care and help you plan for your next visit. With telehealth, your care team can work with other providers, including distant specialists. Care using telehealth may be more convenient than in person care.

My consent to use telehealth: My healthcare team will explain to me the benefits and risks of telehealth, and the types of services that might help me. I understand my provider may use telehealth to examine, consult, diagnose, and/or treat me and that this treatment will be documented in my medical record. I know that I have the right to ask questions and receive guidelines about the services offered to me. My use of telehealth is my choice and no one else can decide that for me. I know I have the right to know who will be involved in my healthcare. This includes the people who will be with me in person and the people who will be at the distant site to care for me. I know I also have the right to exclude anyone from either site and I have the right to object to the videotaping or other recording of a telehealth service.

I know I can stop using telehealth at any time and request the same service(s) in a face-to-face setting. I know that if I choose the face-to-face services, my care team may change.

I know that information about me may be created, stored, used or disclosed in linking me with telehealth services. This information is protected health information and will be handled using the standards applied to all protected health information. I know I have the right to access my protected health information under state and federal law.

If I am a MaineCare beneficiary, my refusal of telehealth will not affect my MaineCare benefits. In some circumstances, MaineCare will pay me to travel to receive MaineCare covered services under the MaineCare Benefits Manual.

Risks: I know that the computer systems used to deliver telehealth are made to protect others from knowing who I am and/or anything about my health information. Rarely, equipment or security failures can occur despite these protections and my personal information could be exposed. Sometimes, technical problems or the type of health problem being treated result in the transmission of information that is not adequate for medical decision making, which may delay my treatment. In some cases, an in-person visit may be needed.

Acknowledgement: My signature below shows that I have read and understand the risks and benefits of telehealth. I will have the chance to discuss telehealth services with my healthcare team and I will raise any questions or concerns with them.

Patient Consent: By clicking the box reading I agree to EMHS eVisits Terms of Use, EMHS eVisits Privacy Policy and EMHS Patient Informed Consent for Telehealth services, I intend this to be my electronic signature showing that I consent to receive telehealth services.