Telemedicine Session - Patient Authorization and Consent

Foundation Psychiatry, P.C. -- 35 Collier Road NW, Suite 425, Atlanta, GA 30309 -- Tel: (404) 902-6184 | Fax: (404) 400-1952

Effective Date: [09/17/2026] | Version: 1

Patient First Name

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Patient Last Name

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Telemedicine Session — Patient Authorization and Consent

Telemedicine lets a doctor or other healthcare provider care for you, even when you cannot see him or her in person. The doctor uses the Internet or other technology to give you advice, give you an exam, or do a procedure through online communications. Telemedicine can also be used to get prescription refills, book an appointment, or let your doctor talk with other providers about your health problem or treatment.

Voluntary Consent and Right to Decline

You may choose not to receive services by telehealth. You may ask for an in-person visit when appropriate, or withdraw your consent to telehealth at any time. Choosing not to use telehealth will not affect your right to receive other available care or services.

Benefits, Risks, and Limitations

Telehealth may make it easier to receive care without traveling to the office. Technical problems may interrupt the visit; the provider may not be able to perform all parts of an in-person examination; and the provider may decide that in-person care, emergency evaluation, or another type of care is needed.

All laws about the privacy of your health information and medical records apply to telemedicine. These laws also apply to any video, photo, and audio files that are made and stored in connection with your care.

Your Telehealth Session — Participants and Privacy

You will be told if another person is present with the provider, such as a trainee, interpreter, nurse, or technology-support staff member. You may tell us if someone is present with you. Please participate from a private location whenever possible.

Location, Callback Number, and Emergency Response

At the beginning of each telehealth visit, you must tell us your current physical location, phone number, and emergency contact information. If there is an emergency or connection loss during an urgent situation, the provider may contact 911, mobile crisis services, your emergency contact, or local emergency resources.

Technology and Modalities

Foundation Psychiatry offers telehealth visits by video (using Google Meet, Doximity, Doxy.me, or another HIPAA-secure platform) or by audio-only telephone call, depending on your preference and clinical appropriateness. If your connection drops or the platform fails during a visit, your provider will call you directly to continue or reschedule the appointment.

Recording of Telehealth Sessions

Sessions may be recorded for clinical documentation purposes (for example, using AI-assisted documentation tools). If a session is recorded, your provider will ask for your verbal consent at that time.

Georgia Medicaid Disclosures

If you are a Georgia Medicaid member, you have the right to refuse telehealth services. Before your initial telehealth visit, you will be informed of the risks, benefits, and consequences of receiving care by telehealth, and your signed consent will be obtained and retained in your record. Your images and health information will not be shared or disseminated without your written consent.

Your Telehealth Session — What to Expect

During your telehealth session: the provider and staff will introduce themselves; you may be asked to confirm the state you are in and the state where you live; the provider may talk to you about your health history (other providers may take part in this discussion); a nurse, PA, NP student, or other healthcare staff may be participating in the appointment; non-medical staff may be in the room to help with the technology.

Patient Acknowledgment

By signing below, I confirm that: I have been told the name and credentials of my telemedicine provider; I have been able to ask questions about telemedicine sessions; all of my questions have been answered; I understand no guarantees have been made about success or outcome; and I agree to take part in a telemedicine session under the terms described above.

Signatures

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By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Patient Name (Print)

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Date of Birth

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Date

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Personal Representative Name / Relationship (if applicable)

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Date

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Interpreter Name (if used)

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Date

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