Peak Health Medical
– Informed Consent for Telehealth Visit
Effective Date: October 15th, 2025
Updated: July 28, 2026
I hereby consent to receiving treatment through telehealth from my Peak Health Medical clinician or a qualified member of the Peak Health Medical care team. “Telehealth” is the delivery of health‑care services—and related public‑health activities—via information and communication technologies to facilitate diagnosis, consultation, treatment, education, care management, and self‑management of a patient’s health care. Telehealth involves the oral and visual transmission of my medical information to clinicians located at Peak Health Medical–affiliated facilities or elsewhere.
My rights with respect to telehealth
Voluntary participation. I may withhold or withdraw consent at any time without affecting my right to future care or treatment or risking the loss of any program benefits to which I am otherwise entitled.
Access to in‑person care. Telehealth does not prevent me from receiving in‑person services, now or in the future. My Peak Health Medical clinician will decide whether a particular service is clinically appropriate for delivery via telehealth.
Confidentiality. Information disclosed during treatment is generally confidential. Mandatory or permissive exceptions include, but are not limited to, reporting child, elder, or dependent‑adult abuse; expressed threats of violence toward an identifiable victim; and circumstances in which my mental or emotional state becomes an issue in legal proceedings. Personally identifiable images from the telehealth interaction will not be disseminated without my written consent.
Potential benefits and risks. I may benefit from telehealth, but results are not guaranteed. Risks include, among others, interruption of the audio‑video connection or delays in treatment due to technological failures.
Access to records. I have the right to access my health information and obtain copies of my medical records in accordance with state and federal law.
Opportunity for questions. I may ask questions at the start of my telehealth consult. My clinician will answer them, and I may decline to continue the consultation at any time.
Acknowledgment and consent
By beginning my telehealth consult, I confirm that I have read and understand this Informed Consent, that my name and identity have been correctly identified, and that I give my informed consent to receive treatment via telehealth from Peak Health Medical.