This form describes Patient First’s Telehealth treatment and payment policies and includes:
If I am signing on behalf of a minor, incapacitated or otherwise legally dependent patient, I certify that I am a person with legal authority to act on behalf of the patient, including the authority to consent to medical services, and I accept financial responsibility for services rendered.
Patient First will protect the privacy of my health information and will not use or disclose it except as permitted by law. Patient First’s privacy policies are more fully described in the Privacy Notice, which is available for review and download here: https://www.patientfirst.com/patient-first-privacy-practices. By signing this Consent, I acknowledge receipt of the Privacy Notice and consent to Patient First’s use and disclosure of my health information in accordance with its terms. I understand that all existing confidentiality protections that apply to in-person treatment apply to telehealth services.
New Jersey patients only: By signing this consent electronically, I authorize Patient First to disclose information related to HIV/AIDS for treatment, payment, health care operations, and other purposes consistent with the Privacy Notice. I may revoke consent by sending written notice as required by the Privacy Notice. Revocation will be effective upon receipt, except to the extent that Patient First has already taken action in reliance on my consent.
I acknowledge, understand and agree that:
I understand that I may access and print a copy of this Consent here: https://www.patientfirst.com/portals/0/Legal/TelehealthServicesConsent.pdf.