Telehealth consent

BY RECEIVING SERVICES FROM A TRUHEARING PROVIDER THROUGH TELEHEALTH, YOU ARE CONSENTING TO THE TERMS OUTLINED BELOW. PLEASE READ IT CAREFULLY. IF YOU DO NOT CONSENT TO/AGREE WITH ANY OF THESE TERMS, PLEASE INFORM THE TRUHEARING PROVIDER AND DO NOT ACCEPT SERVICES PROVIDED VIA TELEHEALTH. THE TRUHEARING PROVIDER OR REPRESENTATIVE MAY ASK IF YOU UNDERSTAND AND AGREE WITH THESE TERMS. YOU MAY ASK THE TRUHEARING PROVIDER ANY QUESTIONS YOU MAY HAVE REGARDING THE TELEHEALTH SERVICES HE OR SHE WILL BE PROVIDING.

1. I voluntarily consent to receive services from a TruHearing Provider through telehealth (remote care) technology.
2. I understand that the TruHearing Provider and I will communicate by teleconference or other electronic means and that the TruHearing Provider will provide services remotely. I understand that there are no guarantees regarding outcomes and results of these telehealth services.
3. It has been explained to me how telehealth technology will be used. I understand that the interactions I will have with the TruHearing Provider through telehealth technology may be different than the interactions I would have during an in-person office visit because I will not be in the same location as the TruHearing Provider and will not have direct, physical contact with the TruHearing Provider.
4. I understand that there are risks inherent to telehealth technology, including, but not limited to, interruptions, potential unauthorized access to information shared over a phone or internet connection (including, potentially, unauthorized access to my health information), technical difficulties, issues with the quality of transmitted data which may affect the quality of services received through telehealth, the inability to change the environment and/or test conditions, and limitations of hearing examinations provided through telehealth technology. I understand that I may discontinue telehealth services at any time if I am uncomfortable receiving services via telehealth or if any necessary internet and/or phone connection is inadequate. I also understand that the TruHearing Provider may elect to discontinue providing services through telehealth. If I elect to not receive or discontinue receiving services via telehealth or if the TruHearing Provider elects to discontinue providing services through telehealth, I understand that I may coordinate with TruHearing to receive services via telehealth through another TruHearing Provider or via a traditional, in-person visit, if available in my area.
5. I understand and acknowledge that I or the TruHearing Provider may find it necessary and/or useful for others to be present while I receive services through telehealth in order to operate the telehealth technology or otherwise facilitate the receipt of services through telehealth. I understand that any such individuals utilized by the TruHearing Provider are bound to maintain the confidentiality of all information discussed. I understand that my personal information, including my health information, will be discussed in the presence of anyone present with me while I receive services through telehealth, and I consent to such disclosure. I also understand that, if others are present, I may ask them to leave and/or discontinue telehealth services if I am not comfortable with their presence.
6. I understand that the TruHearing Provider will not initiate follow-up consultations unless expressly agreed upon during my telehealth visit and that it is my responsibility to initiate any necessary follow-up telehealth visits.
7. I understand that the services being provided through telehealth may be recorded by the TruHearing Provider for treatment purposes and consent to such recording. The TruHearing Provider will keep any such recording confidential in accordance with applicable law.
8. I understand that the TruHearing Provider will securely store my electronic communications in accordance with The Health Insurance Portability and Accountability Act of 1996 (HIPAA) and keep all electronic communications confidential in accordance with applicable law. Only the TruHearing Provider will have access to my communications unless he or she determines that another provider, clinic staff, and/or TruHearing must access my communications in order to provide adequate patient care.
9. I authorize the TruHearing Provider to release any of my relevant health information as allowed or required by law. I further authorize the TruHearing Provider to release any information to my insurance company or any other party that may be responsible for payment for my treatment. 
10. I understand that I have the right to withdraw this consent at any time.
11. I understand that I may report any complaints I have about the services I receive via telehealth by calling TruHearing at 866-581-9464.
12. I understand that I will receive the TruHearing Provider’s contact information and that I may communicate with the TruHearing Provider by phone and/or through my hearing aid app. The TruHearing Provider will respond to my routine electronic messages by phone, email, or through my hearing aid app within three (3) business days. I understand that the TruHearing Provider will contact me via phone or email if an emergency or other situation that will impact my care arises (e.g., last minute appointment cancellations, unscheduled office closures, important updates about my care, etc.).
13. I have read (or have had read to me) these terms carefully and consent to receive services through telehealth pursuant to these terms.