Telehealth Consent

Last Updated: August 31, 2026
 

PATIENT INFORMED CONSENT FOR TELEHEALTH SERVICES

 

Please Note: Telehealth involves the delivery of healthcare services using electronic communications, information technology, or other means between a healthcare practitioner and a patient who is not in the same physical location.

1. TELEHEALTH SERVICES OVERVIEW & DISCLOSURE

By agreeing to proceed, I understand and consent to receive medical care and telehealth services from healthcare providers associated with OpenDoor Health PLLC ("OpenDoor Health"). Telehealth services may include video conferencing, audio communications, secure asynchronous messaging, electronic health record (EHR) transmission, and remote review of medical records.
 

2. EXPECTED BENEFITS & POTENTIAL RISKS

Benefits: Enhanced access to healthcare evaluation, timely clinical consultation, convenience, and reduced travel burden.

Risks: As with any medical procedure or modality, there are potential risks associated with telehealth, including but not limited to: technical interruptions or failures; delay in evaluation due to equipment issues; clear images or clinical details being insufficient for diagnosis; misdiagnosis or delayed diagnosis; and rare security protocol failures leading to privacy risks. In the event of a technology failure during a session, the provider will attempt to re-establish connection via phone or secure portal.
 

3. MEDICAL EMERGENCY NOTICE

I understand that telehealth services provided by OpenDoor Health are NOT intended for medical emergencies. If I am experiencing a medical emergency, acute chest pain, severe shortness of breath, severe bleeding, or thoughts of self-harm, I will immediately call 911 or proceed to the nearest emergency room.

 

4. PRESCRIPTION HISTORY & ELECTRONIC PRESCRIBING AUTHORIZATION

I explicitly authorize OpenDoor Health and its clinical providers to query, retrieve, and review my historical prescription medication records electronically via ScriptSure or other electronic prescribing systems, pharmacy benefit managers (PBMs), and national prescription data clearinghouses. I understand that obtaining an accurate medication history is vital for patient safety, preventing adverse drug interactions, and optimizing treatment plans.

 

5. PHARMACY COMMUNICATION & INSURANCE PRIOR AUTHORIZATION

I authorize OpenDoor Health and its clinical staff to communicate directly with retail, mail-order, and specialty pharmacies regarding my prescriptions, dosage instructions, refills, and safety verifications. Furthermore, I authorize OpenDoor Health to submit necessary clinical documentation, medical records, and prior authorization paperwork to my insurance provider or pharmacy benefit manager on my behalf to facilitate coverage for prescribed medications and services.
 

6. PRIVACY, CONFIDENTIALITY & RIGHTS

All existing confidentiality protections under state and federal law (including HIPAA) apply to my telehealth interactions and records. I understand that:

• I have the right to withhold or withdraw consent to telehealth services at any time without affecting my right to future care or treatment.

• I have the right to access my medical records in accordance with applicable law.

• My provider will determine whether the condition being treated is appropriate for telehealth care. If in-person care is required, I will be referred accordingly.
   

7. PATIENT ACKNOWLEDGEMENT

I certify that I have read and fully understand this consent form. I have had the opportunity to ask questions, and all my questions have been answered to my satisfaction. By agreeing to continue, I voluntarily consent to telehealth care, prescription history access, pharmacy communications, and insurance prior authorization processing by OpenDoor Health, PLLC.