HIPAA Consent & Authorization

1. Consent for Telehealth Services

By accepting this consent, I acknowledge and agree to:

• Receive healthcare services via secure video, audio, or asynchronous messaging
• Understand that telehealth is not appropriate for medical emergencies (call 911)
• Provide accurate health information to my provider
• Follow my current physical location state licensing requirements

2. Authorization to Use & Disclose PHI

I authorize BioMedicineHealth to:

• Share my medical information with my healthcare provider(s) for treatment
• Transmit prescriptions electronically to my chosen pharmacy
• Process payments and submit insurance claims on my behalf
• Send appointment reminders via email or SMS (I can opt out)
• Store consultation recordings for medical record purposes (if applicable)

3. Notice of Privacy Practices

I have been provided access to BioMedicineHealth's Privacy Policy and understand how my Protected Health Information (PHI) will be used and disclosed.

4. Patient Rights

I understand that I have the right to:

• Refuse telehealth services and request in-person care instead
• Revoke this authorization at any time (in writing)
• Access my medical records within 30 days of request
• File a complaint if I believe my privacy has been violated

5. Risks & Limitations of Telehealth

I acknowledge and accept the following risks:

• Delays or disruptions due to technical issues (internet outages, software failures)
• Limitations in physical examination (provider cannot palpate, auscultate in person)
• Potential misdiagnosis if insufficient visual/audio quality
• Risk of data breach despite encryption and security measures (though rare)

6. Informed Consent Statement

By checking the box below, I certify that:

• I have read and understood this consent form
• I have had the opportunity to ask questions
• I voluntarily consent to receive telehealth services
• I authorize the use and disclosure of my PHI as described