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Informed Consent to Telehealth Services


This form describes NY Medical Practice’s Telehealth treatment & payment policies and includes :

·Your consent to receive medical treatment from NY Medical Practice (and your other rights and responsibilities);

  • Your agreement to receive services using telehealth technology; and

  • Your agreement to pay in full any charges that are your responsibility.

By checking the box prior to entering the virtual waiting room of Elizabeth Selz, APRN, NP- BC on the NY Medical Practice’s Doxy portal, I understand and agree that I am signing this consent electronically and that (i) I have reviewed, understand, and accept the risks and benefits of telehealth services as described below and wish to receive such services, and(ii) I agree to the remaining terms of this consent.

  1. By using the NY Medical Practice Doxy portal, I agree to receive telehealth services. Telehealth involves the delivery of health care services, including assessment, treatment, diagnosis, and education, using interactive audio, video, text, and data communications. During my visit, my provider Elizabeth Selz, APRN, NP-BC and I will be able to see and speak with each other from remote locations.


  1. I understand and agree that:


  • I will not be in the same location or room as my medical provider.

  • Elizabeth Selz, APRN, NP-BC is licensed in the state in which I am receiving services. I will report my location accurately during registration.

  • Potential benefits of telehealth (which are not guaranteed or assured) include: (i) access to medical care if I am unable to travel to my provider’s office; (ii) more efficient medical evaluation and management; and (iii) during the COVID-19 pandemic, reduced exposure to patients, medical staff, and other individuals at a physical location.

  • Potential risks of telehealth include: (i) limited or no availability of diagnostic laboratory, x-ray, EKG, and other testing, and some prescriptions, to assist my medical provider in diagnosis and treatment; (ii) my provider’s inability to conduct a hands-on physical examination of me and my condition; and (iii) delays in evaluation and treatment due to technical difficulties or interruptions, distortion of diagnostic images or specimens resulting from electronic transmission issues, unauthorized access to my information, or loss of information due to technical failures. I will not hold Elizabeth Selz, APRN, NP-BC responsible for lost information due to technological failures.

  • I further understand that Elizabeth Selz, APRN, NP-BC advice, recommendations, and/or decisions may be based on factors not within her control, including incomplete or inaccurate data provided by me. I understand that Elizabeth Selz, APRN, NP-BC relies on information provided by me before and during our telehealth encounter and that I must provide information about my medical history, condition(s), and current or previous medical care that is complete and accurate to the best of my ability.

  • I may discuss these risks and benefits with Elizabeth Selz, APRN, NP-BC and will be given an opportunity to ask questions about telehealth services. I have the right to withdraw this consent to telehealth services or end the telehealth session at any time.

  • I understand that the level of care provided by Elizabeth Selz APRN, NP-BC is to be the same level of care that is available to me through an in-person medical visit. However, if my provider believes I would be better served by face-to-face services or another form of care, I will be referred to the nearest medical center, hospital emergency department or other appropriate health care provider.

  • In case of an emergency, I will dial 911 or go directly to the nearest hospital emergency room.


  1. I consent to, understand, and agree that:


  • I have the right to discuss the risks and benefits of all courses of treatment proposed by Elizabeth Selz, APRN, NP-BC, together with any available alternatives.

  • Elizabeth Selz, APRN, NP- BC will provide care consistent with the prevailing standards of medical practice but makes no assurances or guarantees as to the results of treatment.

  • Before prescribing any controlled substance to me, Elizabeth Selz, APRN, NP-BC may review information from the Prescription Drug Monitoring Program in my state of residence regarding my prior receipt of controlled substances.

  • The laws of the state in which I am located will apply to my receipt of telehealth services.

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