Consent – Telehealth Phone Visit Patient Consent for Audio-Only (Telephone) Telehealth Visits Updates I. PATIENT INFORMATION (to be completed by the patient or legal representative)First NameLast NameMonth- Select -JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberDay- Select -12345678910111213141516171819202122232425262728293031YearAddress - 18607 Ventura Blvd, Ste 102 Tarzana CA 91356. ### incomplete addresses will not be accepted ### Preferred Phone for visitsII. CONSENT STATEMENTS (check or initial **each** box) I confirm that I do not have, cannot operate, or prefer not to use video technology for medical visits at this time. I understand the visit will occur by telephone only and will involve real‑time, two‑way voice communication without video. I choose to receive care in this manner and know I may request an in‑person or video visit at any time without affecting my right to future care or benefits. I acknowledge that my clinician cannot perform a visual examination over the phone and that this may limit the ability to fully diagnose or treat me. If my clinician determines that audio‑only is not clinically appropriate, I may be asked to schedule an in‑person or video visit. Telephone visits will be conducted over a secure line when available, but no technology is completely secure. I accept the small risk of inadvertent disclosure. Audio‑only telehealth is not for medical emergencies. If I believe I am experiencing an emergency, I will call 911 or go to the nearest emergency department. These services are billed to Medicare or my health plan using the rules in 42 CFR 410.78 and CMS guidance in the Calendar Year 2025 Physician Fee Schedule Final Rule. Standard copayments or coinsurance may apply, and I will be responsible for any unpaid balance. I may withdraw this permission at any time by notifying Thrive Comprehensive Medical Group in writing. Withdrawal will not affect care already provided.III – PATIENT OR LEGAL REPRESENTATIVE ATTESTATION I have read (or had read to me) the information above. All of my questions have been answered. By signing below, I freely give my informed consent to receive audio‑only telehealth services from Thrive Comprehensive Medical Group.Signature of patient or legal representative Sign HereFirst NameLast NameDate / TimeRelationship to patient if not self (Parent, Guardian, POA, Other)IV – OFFICE USE ONLYUploaded to EHR: Yes ☐ No ☐Staff initials: ________TextareaSubmit Form
