Informed Consent for Telehealth Services
Last Updated: June 25, 2026
Telehealth involves the use of live audio-video electronic communications to deliver health care services to patients while the health care provider (the “Provider”) is located at a different physical location from the patient. Telehealth services can improve patient care by offering efficient medical evaluation and improved access to care. By clicking where indicated, you consent to receive telehealth services from Haven Health of California, P.C. (“Haven Health”) on the terms set forth in this Informed Consent for Telehealth Services (this “Consent”).
By joining the telehealth encounter and receiving services through Haven Health’s telehealth platform, I acknowledge and agree to each of the following:
1. Provider Location. My Provider will be at a different physical location than me during the telehealth visit.
2. Not Emergency Services. Telehealth services are not intended to serve as, and do not constitute, emergency medical care. If I am experiencing what I believe to be a medical emergency — including any condition I believe to be life- or limb-threatening, such as severe chest pain, difficulty breathing, choking, loss of consciousness, or any other life-threatening emergency — I should call 911 immediately and seek in-person emergency care. I should not rely on telehealth services in a medical emergency. After seeking emergency care, I may contact Haven Health for follow-up consultation.
3. Accurate Health Information. It is my responsibility to provide accurate, complete, and current information about myself and my health conditions to my Provider. I have fully disclosed to Haven Health all historical, current, and/or ongoing health conditions, impairments, illnesses, or other matters that may be relevant to my care. I understand that no guarantees or promises as to the results of my care have been made by Haven Health or my Provider, and I have the right to ask questions regarding my treatment and its potential risks.
4. Right to Withdraw Consent. I can withhold or withdraw consent to receive telehealth services at any time without affecting my right to future care or treatment. Either I or my Provider may discontinue the telehealth visit if either of us determines that telehealth is not appropriate for my health care needs at that time.
5. Financial Responsibility. I am financially responsible for: (a) any charges I may incur from my mobile or internet service provider in connection with the telehealth visit; and (b) all charges for services that are not covered by my health insurance plan, including any applicable deductibles, copayments, and coinsurance. It is my responsibility to determine whether my insurance covers telehealth services and, if required by my insurance plan, to obtain any necessary prior authorization or referral before my visit. Failure to obtain required prior authorization may result in a reduction or denial of benefits, and I will be responsible for any resulting balance. I acknowledge that I have received a copy of Haven Health’s Financial Responsibility Policy and that the payment information I have provided to Haven Health is accurate, complete, and current.
6. Identity and Location Verification. I agree to verify my identity and current location to Haven Health at the start of each telehealth visit. I understand that failure to comply with identity and location verification procedures may result in termination of the visit.
7. Confidentiality and Privacy. Haven Health has made reasonable and appropriate efforts to reduce the confidentiality risks associated with telehealth services. I am also responsible for protecting my own privacy during the visit — for example, by joining from a private space, ensuring others cannot overhear my conversation or view my screen, and using a secure internet connection. All existing confidentiality protections under federal and California state law apply to information I disclose during telehealth services.
8. Use and Disclosure of Health Information; Notice of Privacy Practices. My Provider may use, share, or disclose my health information for treatment, payment, and health care operations purposes, with other health care providers for continuity of care, or for any other purposes in accordance with Haven Health’s Notice of Privacy Practices and as permitted by applicable law. I acknowledge that I have received and reviewed a copy of Haven Health’s Notice of Privacy Practices.
9. Medical Records. All medical information transmitted during my telehealth visits may be incorporated into my medical record and may be shared with other health care providers and entities for continuity of care or as otherwise permitted under applicable law. All existing laws regarding access to my medical information apply to telehealth services.
10. Technology Risks. There are potential risks to using audio-video technology for health care visits, including but not limited to interruptions, unauthorized access, technical difficulties, and call termination. I acknowledge and accept those risks and understand that alternatives to telehealth services, including in-person care, are available.
11. Non-Secure Communication Platforms. I understand that certain communication platforms may not provide a fully HIPAA-compliant means of communication. If I choose to initiate or send protected health information through a non-secure platform, I am knowingly consenting to that method of communication and agree that Haven Health is not liable for any unauthorized access to information transmitted through such platforms. I understand that Haven Health recommends using encrypted, HIPAA-compliant platforms for all communications involving my health information, and that Haven Health will limit the content of electronic communications to the minimum amount necessary.
12. Communications Consent. I understand and agree that Haven Health may contact me using automated calls, emails, and/or text messages sent to the phone number(s) and email address I have provided. These communications may include appointment reminders, treatment recommendations, billing notices, and other practice communications. I may opt out of receiving any such communications by notifying Haven Health.
13. Opportunity to Ask Questions. I have had a sufficient opportunity to ask questions about telehealth services, and I have no remaining questions or concerns that would prevent me from participating. If questions arise during or after my visit, I understand it is my responsibility to contact my Provider.
14. Authority to Consent. I am at least 18 years of age and am legally authorized to consent to these terms on my own behalf. To the extent I am consenting on behalf of another individual who will be receiving telehealth services during this encounter, I represent and warrant that I am legally authorized to do so on their behalf.
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By clicking where indicated, I represent that I have read and understand this Informed Consent for Telehealth Services; I have been advised of the potential risks, benefits, and alternatives of telehealth services; I have had the opportunity to ask questions and have no remaining questions at this time; and I hereby give my informed consent to receive telehealth services from Haven Health and/or the medical care of any individual for whom I am legally authorized to consent, as applicable.
