Telehealth Information

TeleVisit Appointment Consent Form

I understand that a TeleVisit appointment involves the use of electronic devices such as a computer, tablet, smart phone or telephone to enable two-way communication between the patient and their provider at different locations for the purpose of diagnosis, treatment, therapy, follow-up and /or education.

Transmitted information may include any of the following:

• Patient medical records
• Live two-way audio and video
• Patient materials such as prescriptions, test orders, and patient education
• Pictures from the patient to the provider

I consent for my medical, dental, and/or behavioral health provider at the Community Health Center of the New River Valley to conduct a health care appointment with me through a TeleVisit appointment.
I understand that the laws that protect privacy and the confidentiality of my medical information also apply to TeleVisits.

I understand that my insurance carrier will have access to my medical records for quality review/audit as they would with an in-person office visit.

I understand that I will be responsible for any copayments, deductibles or coinsurances that apply to my TeleVisit appointment.

I understand that I have the right to withhold or withdraw my consent for the use of TeleVisits during my care at any time, without affecting my right to future in-person care or treatment.

I may revoke my TeleVisit consent in writing at any time by contacting:

Community Health Center of the New River Valley
Ashley Slagel-Perry, Privacy Officer
215 Roanoke St.
Christiansburg, VA 24073
540-381-0820

This consent is valid for one year from the date the consent was signed and dated and my provider at the Community Health Center of the New River Valley may provide health care services to me via TeleVisit without the need for me to sign another consent form.

Telemedicine Informed Consent Form

In Case of Emergency