Telehealth Informed Consent
Effective Date: June 1, 2026
Before your first telehealth visit with Ebenezer Telehealth, please read this document carefully. It describes the nature of telehealth services, their potential benefits and risks, and your rights as a patient. Please review it carefully.
This Telehealth Informed Consent (“Consent”) is provided by Ebenezer Telehealth (“we,” “us,” or “our”) to inform you about the use of telehealth technology in your healthcare. Your participation in telehealth services is entirely voluntary. Please read this information carefully before consenting to a telehealth appointment.
1. What Is Telehealth?
Telehealth refers to the delivery of healthcare services using electronic communications technologies — such as secure video, audio, and messaging — that allow a provider and patient to interact remotely when they are not in the same physical location.
At Ebenezer Telehealth, your appointments take place via secure, HIPAA-compliant video or audio platforms. Your provider conducts consultations, reviews your health history, assesses your concerns, and provides medical guidance through this technology. All telehealth visits are conducted with the same standard of care and professionalism as in-person appointments.
2. Potential Benefits of Telehealth
Telehealth services may offer the following benefits:
- Convenient access to care from the comfort of your home or workplace
- Reduced travel time and associated costs
- Greater flexibility in appointment scheduling
- Access to a specialized healthcare provider without having to travel to a clinic
- Continuity of care between in-person visits
- Reduced exposure to illness in waiting rooms and clinical settings
- Care for those with mobility limitations, transportation barriers, or time constraints
3. Limitations of Telehealth
Telehealth is not appropriate for all medical conditions and has inherent limitations compared to in-person care. You should be aware of the following:
- Your provider cannot perform a physical examination during a telehealth visit.
- Certain diagnostic tests — such as blood work, urinalysis, imaging, or physical assessment — require an in-person visit or referral to a local facility.
- Some conditions may be difficult to accurately assess without a hands-on clinical examination.
- Prescribing controlled substances via telehealth is subject to additional state and federal regulatory requirements that may limit what can be prescribed remotely.
- Telehealth is not a substitute for emergency or urgent in-person care.
4. Risks and Technology Considerations
As with any healthcare service, telehealth carries certain risks. By proceeding with a telehealth visit, you acknowledge and accept these potential risks:
Technology Failure
Internet connectivity issues, equipment failure, software problems, or power outages may interrupt or prevent a telehealth session from occurring. In such cases, your provider may attempt to contact you by phone or the appointment may need to be rescheduled at no additional charge for the interruption.
Incomplete Clinical Information
Without the ability to conduct a physical examination or use in-office diagnostic tools, there is an inherent risk that clinically relevant information may not be captured during a telehealth visit. This may affect diagnostic accuracy or treatment decisions, and may necessitate a referral for in-person evaluation.
Privacy and Security
Despite our use of HIPAA-compliant, encrypted technology platforms, no method of electronic transmission is entirely free from the risk of interception or unauthorized access. You acknowledge that this risk exists and that we take reasonable and required measures to minimize it.
Your Environment
You are responsible for conducting your telehealth visit in a private, secure location where third parties cannot overhear or observe the session without your knowledge. Ebenezer Telehealth is not responsible for privacy breaches that occur on your end due to your surroundings or personal devices.
5. Privacy and Security Measures
Ebenezer Telehealth takes your privacy seriously. We use the following measures to protect your health information during telehealth visits:
- HIPAA-compliant, end-to-end encrypted video and audio platforms
- Secure, password-protected electronic health records (EHR) systems
- Access to your health information is limited to authorized clinical and administrative staff only
- Business Associate Agreements (BAAs) are in place with all technology vendors who handle your protected health information (PHI)
- Regular staff training on HIPAA compliance and data security best practices
For full details on how we handle your protected health information, please review our HIPAA Notice of Privacy Practices.
6. Provider Credentials
Your telehealth services at Ebenezer Telehealth are provided by a licensed advanced practice provider:
Dr. Susan George, DNP, APRN, BC-ADM
- Doctor of Nursing Practice (DNP)
- Advanced Practice Registered Nurse (APRN)
- Board-Certified in Advanced Diabetes Management (BC-ADM)
- Licensed in the State of Oklahoma
You have the right to verify provider credentials through the Oklahoma State Board of Nursing or to request this information directly from our office prior to your appointment.
7. Your Rights as a Patient
You have the following rights regarding telehealth services at Ebenezer Telehealth:
Right to Refuse
You have the right to refuse telehealth services at any time, before or during an appointment, without affecting your right to receive future care. Refusal of telehealth will not result in any penalty or negative treatment.
Right to Request In-Person Referral
You have the right to request an in-person referral at any time if you feel that a telehealth visit is not meeting your needs, or if your provider determines that in-person evaluation is clinically appropriate. We will assist in coordinating referrals as needed.
Right to Confidentiality
Your health information disclosed during telehealth visits is protected under HIPAA and applicable Oklahoma state privacy laws. It will not be shared without your authorization except as described in our HIPAA Notice of Privacy Practices.
Right to Ask Questions
You have the right to ask questions about your treatment, the technology being used, your diagnosis, and any aspect of your telehealth visit — before, during, or after the appointment.
Right to Withdraw Consent
You may withdraw your consent to receive telehealth services at any time by notifying us in writing or verbally during a session. Withdrawal of consent will not affect the quality of any future care you receive through available channels, nor will it result in any penalty.
8. Patient Acknowledgment
By scheduling and/or attending a telehealth appointment with Ebenezer Telehealth, you confirm that:
- You have read and understand this Telehealth Informed Consent.
- You understand the benefits, limitations, and risks of telehealth services as described above.
- You voluntarily consent to receive healthcare services via telehealth technology.
- You understand that telehealth is not appropriate for emergencies, and you know to call 911 or go to your nearest emergency room in any medical emergency.
- You confirm that you are physically located in the State of Oklahoma at the time of your appointment.
- You understand your right to refuse telehealth services or request an in-person referral at any time.
Note: A formal signed consent form may also be collected electronically during your intake or booking process. This page serves as your informational disclosure. If you have any questions about this consent before your appointment, please contact us.
9. Questions & Contact
If you have any questions about this consent, telehealth services, or your rights as a patient, please contact us before your appointment:
Ebenezer Telehealth
Oklahoma City, OK
Phone: (405) 349-8188
Also review our HIPAA Notice of Privacy Practices, Privacy Policy, and Terms of Use.