Telehealth Services Consent Form


When an Xpress Urgent Care clinic believes a patient may benefit from the use of telehealth services to establish or maintain continuity of care with an Xpress Urgent Care clinician, the clinic may recommend the application of telehealth services to assist, examine, or coordinate care. Telehealth services often provide a broader access to medical care, eliminates wait times, and increases comfort and familiarity for patients and their families.

Telehealth services are a way to deliver healthcare services to patients when the patient can’t visit an Xpress Urgent Care facility, or is recommended against visiting an urgent care clinic due to special circumstances, such as a health risk or disease outbreak. Telehealth services are generally defined as the use of electronic information, communications technology, and application of medical instruments to exchange medical information from one site to another site, and to provide medical treatment to a patient and/or to participate in the medical diagnosis of, or medical opinion or medical advice to a patient. 

Telehealth services may entail the transfer medical information through the use of interactive, real-time audio/visual technology (i.e. video conferencing) or electronic data interchange (i.e. computer-to-computer exchanges), or it may transfer medical information through the use of store-and-forward technology (i.e. emails). While precautions are taken to secure the confidentiality of telehealth services, the electronic transmission of medical information can be incomplete, lost or otherwise disrupted by technology failures. Additionally, despite such measures, the transmission and storage of medical information can be accessed by unauthorized persons, causing a breach of the patient’s privacy.

By signing this consent form, I understand and agree:

  1.  I have the right to withdraw consent to the use of telehealth services at any time and receive in-person healthcare services with my clinician.
  2.  I am physically located in California. At the beginning of each telehealth session, I will help my clinician to complete a check-in to assess the suitability of using telehealth services by verifying my full name, my current location, my readiness to proceed, and whether I am in a situation conducive to private, uninterrupted communication.
  3.  Clinician is located in and licensed by the State of California. My clinician may not be able to prescribe medications for me and/or may not be able to assist me in an emergency situation. If I require emergency care, I may call 911 or proceed to the nearest hospital emergency room for help.
  4.  I submit to the exclusive jurisdiction of the California state superior courts and agree that any claim, lawsuit, or other legal proceeding arising out of or relating to the telehealth services provided by my clinician and my clinician’s staff will be brought solely and exclusively in California state superior courts. I also agree that the interpretation of this consent will be exclusively governed by and construed in accordance with the laws of California
  5.  My clinician believes that telehealth services are appropriate for my medical condition and that I would benefit from its use despite its risks and limitations. While I may expect anticipated benefits from the use of telehealth services, no specific results can be guaranteed or assured.
  6.  If my clinician believes at any time that another form of services (i.e. a traditional in-person consultation) would be appropriate, my clinician may discontinue telehealth services and schedule an in-person consultation or refer me to a healthcare provider in my area who can provide such services.
  7.  I received an explanation of how the electronic communications technology will be used for the virtual services. I am comfortable with using electronic communications technology to communicate with my clinician and understand there are limitations to the technology which may require an in-person consultation.
  8.  The laws that protect privacy and the confidentiality of my medical information also apply to telehealth services. The medical information that is transmitted electronically by my clinician to me will be encrypted during transmission and will be stored only by my clinician or a service clinician selected by my clinician. I understand the dissemination of any personally-identifiable images or information from the telehealth communication to researchers or other healthcare providers will not occur except as required by federal or California state law.
  9.  I understand my risks of a privacy violation increase substantially when I enter information on a public access computer, use a computer that is on a shared network, allow a computer to “auto remember” usernames and passwords, or use my work computer for personal communications. I also understand it is my responsibility to encrypt medical information I transmit electronically to my clinician and my failure to use technical safeguards, such as encryption, increases my risks of a privacy violation.
  10.  I understand that no part of the live video encounter will be recorded without my written consent.
  11.  I have the right to access my medical information and obtain copies of my medical records in accordance with California law.
  12.  I understand that the telehealth services provided to me will be billed to my health insurance company and that I will be billed for any patient responsibility as per my insurance.

I read and understand the information provided in this Telehealth Consent Form. I discussed any questions I had with my clinician and all of my questions were answered to my satisfaction,

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