Telehealth Consent Form Template
A plain-language consent form for video and phone visits. It explains what telehealth can and cannot do, the risks and the in-person alternative, how you handle location and emergencies, privacy and recording, and the patient's right to withdraw. Edit it, then print or paste it into your e-signature form.
Pre-filled for an outpatient practice offering video and phone visits. Change the platform, emergency steps, and recording policy to match yours, then print it or copy it into your portal's e-signature form.
Consent to Telehealth Services
Please read before your first video or phone visit — ask us anything that is unclear
1.Patient and provider
2.What telehealth is
3.Benefits, risks, and your choices
4.Your location and emergencies
5.Privacy
6.Consent
Patient or legal representative signature
Date
This template is not legal advice. Informed consent rules for telehealth vary by state and by specialty; have counsel review the form, and check any payer program rules that require documented consent for specific services.
Do You Need Written Consent for Telehealth?
It depends on your state and your specialty. HHS's telehealth guidance for providers says you may be required to get a patient's official informed consent and that the specific informed consent laws vary by state. Some states require written consent, some accept verbal consent recorded in the chart, and some professions set their own rules for therapy and counseling.
A written form is the safe default because it works everywhere. If a patient agrees by phone, record who took the consent, the date, and the time; the form includes a line for exactly that.
What a Telehealth Consent Form Should Cover
| Topic | Why it is on the form |
|---|---|
| What telehealth is and its limits | Patients should know a remote visit cannot include a hands-on exam |
| Risks and alternatives | Informed consent means the patient knows they can choose an in-person visit |
| Location and emergencies | You need to know where the patient is and how to get help if the call drops |
| Privacy on both ends | The patient controls their surroundings; you control yours |
| Observers and recording | Anyone else joining, and any recording, needs the patient's permission |
| Right to withdraw | Consent for telehealth can be withdrawn like any other consent |
HHS also suggests explaining what patients can expect and what their rights are, telling them if anyone is observing the visit and getting consent for that at the start, and having your forms reviewed by your legal team.
Telehealth Consent Is Not the Same as HIPAA Compliance
A signed consent form does not make an unsafe platform acceptable. Under HIPAA, the video or phone vendor that handles patient information needs a signed business associate agreement, and its settings still have to be configured correctly. Compare platforms in our HIPAA-compliant video conferencing review, and check the specifics for Zoom or Microsoft Teams if that is what you use.
Recording visits
A recording of a visit is PHI that has to be stored, protected, and eventually destroyed under your retention policy. Most practices are better off not recording at all, which is why the template says visits are not recorded unless the patient agrees.
Fitting Consent Into the Visit Workflow
- Send the form with the appointment confirmation so it is signed before the first visit.
- Keep it with the procedure consent forms and the rest of the intake packet.
- Confirm the patient's location and call-back number at the start of every visit, not only the first.
- Review the form when you add a new visit type, such as remote monitoring.
Licensure follows the patient