Consent Requirements

Communication Technology-Based Services:  Brief Communication Technology-Based Service, Remote Evaluation of Pre-Recorded Patient Information, Interprofessional Internet Consultation

Consent is required.  It can be verbal and noted in the beneficiaries’ medical record. It is only necessary to obtain consent once annually.

SOURCE: CY 2019 Final Physician Fee Schedule. CMS, p. 31-40 & CY 2020 Final Physician Fee Schedule. CMS, p. 435.

Physician must obtain prior consent from the recipient before services are rendered, this will count as part of each recipient’s benefit limit of 14 annual physician office visits currently allowed.

SOURCE: AL Medicaid Management Information System Provider Manual, Physician Services (28-17). Jan. 2021. (Accessed Feb. 2021).

For rehabilitative services, informed consent is required with specific requirements to be included in the consent.  See manual for details.

SOURCE: AL Medicaid Management Information System Provider Manual, Rehabilitative Services (105-14,15). Jan. 2021. (Accessed Feb. 2021).

No Reference Found

Informed consent standards for telehealth services should adhere to all applicable statutes and policies governing telehealth.

SOURCE: AZ Health Care Cost Containment System. Telehealth and Telemedicine Ch 300, (320-I pg. 3), Oct. 2019. (Accessed Feb. 2021).

Before a provider delivers health care via telehealth, informed consent, written or verbal, is required to be obtained from a member or the member’s Health Care Decision Maker. Exceptions to this consent requirement include:

• If the telehealth interaction does not take place in the physical presence of the member,
• In an emergency situation in which the member, or when applicable, the member’s Health Care Decision Maker is unable to give Informed Consent, or
• Transmission of diagnostic images to a health care provider serving as a consultant or the reporting of diagnostic test results by that consultant.

SOURCE: AZ Health Care Cost Containment System. AHCCCS General and Informed Consent, Ch. 320-Q. pg. 4. 07/01/20. (Accessed Feb. 2021).

A provider must obtain informed consent, as required by applicable state and federal laws, rules and regulations.

SOURCE: AR Medicaid Provider Manual. Section I General Policy.  Rule 105.190.  Updated Aug. 1, 2018. (Accessed Feb. 2021). & AR Admin. Rule 016.06.18. (Accessed Feb. 2021)..

Provider-Led Arkansas Shared Savings Entity (PASSE) Program

Virtual and telehealth services are provide in lieu of providing the same services at a practice site or provided at the individual’s place of residence. Therefore, these services must have patient consent, documented in the patient integrated medical records, and submitted as a claims or encounter from a contracted provider as medically necessary service.

SOURCE: PASSE Program, p. II-9, (3/1/19).  (Accessed Feb. 2021).

Providers must inform the patient about the use of telehealth and obtain verbal or written consent from patients before utilizing telehealth.  If a healthcare provider at the originating or distant site maintains a general consent agreement that addresses the use of telehealth that is sufficient for documentation of patient consent and must be kept in the patient’s medical file.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth. (Aug. 2020), Pg. 5. (Accessed Feb. 2021).

Federally Qualified Health Center (FQHC) & Rural Health Clinic (RHC)

Refer to fee-for-service policy.  All consent for homeless, homebound or migratory or seasonal workers (HHMS) must be documented.

SOURCE: CA Department of Health Care Services (DHCS).  Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHC) Outpatient Services Manual.  Aug. 2020. Pg. 11.  (Accessed Feb. 2021). 

Indian Health Services, Memorandum of Understanding Agreement (IHS-MOA)

Refer to fee-for-service policy. All consent for homeless patients must be documented.

SOURCE: CA Department of Health Care Services (DHCS).  Indian Health Services, Memorandum of Agreement (MOA) 638, Clinics Manual.  Aug. 2020. Pg. 8.  (Accessed Feb. 2021).  

Vision Care

Providers must include a record of the written or verbal request for the consultation by the referring provider or other SOURCE in the medical record.   Verbal and written informed consent from the patient or the patient’s legal representative is required if the consulting provider has ultimate authority over the care or primary diagnosis of the patient.

SOURCE: CA Department of Health Care Services, Vision Care: Professional Services Manual.  (Aug. 2020), Pg. 5.  (Accessed Feb. 2021). 

Local Education Agency:  Speech Therapy

Oral consent must be obtained for the student’s parent or guardian.  The student’s written consent to telehealth is not required.

SOURCE:  CA Department of Health Care Services (DHCS).  Local Education Agency (LEA) Telehealth.  Aug. 2020. Pg. 2.  (Accessed Feb. 2021).

Providers shall give all first-time patients a written statement that includes the following:

• The patient may refuse telemedicine services at any time without affecting the patient’s right to future care or treatment and without risking the loss or withdrawal of any program benefits to which the patient would otherwise be entitled;
• All applicable confidentiality protections shall apply to the services;
• The patient shall have access to all medical information resulting from the services, under state law.

SOURCE: CO Revised Statutes 25.5-5-320. (Accessed Feb. 2021).

Providers must document the member’s consent, either verbal or written, to receive telemedicine services.

The Medicaid requirement for face-to-face contact between provider and member may be waived when treating the member through telemedicine. In-person contact between a health care provider and a member is not required for services delivered through telemedicine that are otherwise eligible for reimbursement.  Prior to treating the member through telemedicine for the first time, the provider must furnish each member with all of the following written statements, which must be signed (electronic signatures will be accepted) by the member or the member’s legal representative:

• The member retains the option to refuse the delivery of health care services via telemedicine at any time without affecting the member’s right to future care or treatment and without risking the loss or withdrawal of any program benefits to which the member would otherwise be entitled.
• All applicable confidentiality protections shall apply to the services.
• The member shall have access to all medical information resulting from the telemedicine services as provided by applicable law for client access to his or her medical records.

These requirements do not apply in an emergency.

SOURCE: CO Department of Health Care Policy and Financing.  “Telemedicine Billing Manual” 11/20.  (Accessed Feb. 2021).

At the time of the telehealth provider’s first telehealth interaction with a patient, the telehealth provider shall inform the patient concerning the treatment methods and limitations of treatment using a telehealth platform and, after providing the patient with such information, obtain the patient’s consent to provide telehealth services. The telehealth provider shall document such notice and consent in the patient’s health record. If a patient later revokes such consent, the telehealth provider shall document the revocation in the patient’s health record.

Consent must be obtained by the parent or the patient’s legal guardian.

SOURCE: CA Gen. Statutes Sec. 19a-906(b)(2).  (Accessed Feb. 2021).

Recipient must provide written consent to use telemedicine. It must be obtained by either the referring, consulting, or distant provider.  An exception is made for involuntary detention and commitment. An exception applies when a DMAP recipient is detained or committed to a facility for care.

SOURCE:  DE Medical Assistance Program.  Practitioner Provider Specific Manual, 2/21/20. Ch. 16.6 & 16.7 Telemedicine, pg. 81-82, & Adult Behavioral Health Service Certification and Reimbursement.  Dec. 14, 2016.  Sec. 1.8. p. 11-13  (Accessed Feb. 2021).

Written consent required.

SOURCE: DC Municipal Regulation. Title 29, Ch. 9, Sec. 910.5. (Accessed Feb. 2021) & Physicians Billing Manual.  DC Medicaid.  (Jan. 13, 2021) Sec. 15.9.2. P. 66 & DC Dept. of Healthcare Finance. Telehealth Provider Guidance. p. 2 (Feb. 2018). (Accessed Feb. 2021).

No Reference Found

Prior to an initial telehealth service, the practitioner who delivers the service to a GA Medicaid Member shall ensure that the telehealth member consent form is provided to the member and signed.  See manual for specific requirements.

SOURCE: GA Dept. of Community Health GA Medicaid Telehealth Guidance Handbook, p. 8 & 59 (Jan. 2021). (Accessed Feb. 2021).

No Reference Found

An appropriate consent is required, which must disclose the delivery models, provider qualifications, treatment methods, or limitations and telehealth technologies.

SOURCE: Idaho Medicaid Provider Handbook. General Information and Requirements for Providers. Jan. 19, 2021, Section 8.9 p. 122.  (Accessed Feb. 2021).

No Reference Found

Providers should always give the member the choice between a traditional clinical encounter versus a telemedicine visit. Appropriate consent from the member must be obtained by the originating site and documentation maintained at both the distant and originating sites.

SOURCE: IN Medicaid Telemedicine and Telehealth Module, Oct. 1, 2019, p. 3. (Accessed Feb. 2021).

Board of Dietetics – Recently Adopted Rule (Effective March 3, 2021)

Prior to the first telehealth visit, a licensee shall obtain informed consent from the individual or group specific to the services that will be provided in a telehealth visit. At a minimum, the informed consent shall specifically inform the individual or group of the following:

• The risks and limitations of the use of technology to provide dietetics services;
• The potential for unauthorized access to protected health information; and
• The potential for disruption of technology during a telehealth visit.

SOURCE:  Iowa Administrative Code Section 645.81.17. (Effective March 3, 2021).(Accessed Feb. 2021).

Signed beneficiary consent for telehealth home services is required.

SOURCE: KS Dept. of Health and Environment, Kansas Medical Assistance Program, Provider Manual, Home Health Agency, p. AIII-19 (Aug. 2020) (Accessed Feb. 2021).

The Cabinet for Health and Family Services must ensure informed consent among Medicaid providers using telehealth.

SOURCE: KY Statute Sec. 205.5591 (2). (Accessed Feb. 2021).

No Reference Found

Prior to the provision of any Telehealth Service, the Health Care Provider shall document that it has provided the educational information to the Member or authorized representative and obtain the Member’s written informed consent to the receipt of Telehealth Services and/or to Store-and-Forward Telehealth Services, Remote Consultation, Virtual Check-In, or Telephone Evaluation and Management. A copy of the signed informed consent shall be retained in the Member’s medical record and provided to the Member or the Member’s legally-authorized representative upon request.

This information should be in a format and manner that the Member is able to understand and include the following:

• Description of the telehealth services and what to expect;
• Explanation that the use of telehealth for this service is voluntary and that the member is able to refuse the telehealth visit at any time without affecting the right to future care or treatment or loss or withdrawal of MaineCare benefit;
• Explanation that MaineCare will pay for transportation to a distant appointment if needed;
• Explanation that the Member will have access to all information resulting from the telehealth service provided by law;
• The dissemination, storage or retention of an identifiable Member image or other information shall comply with federal and state laws and regulations requiring confidentiality.
• Informed of all parties who will be present at the receiving and originating site and have the right to exclude anyone from either site; and
• Member has the right to object to videotaping or other recording of consult.

Written or verbal Member consent for each Remote Consultation must be documented in the Member’s medical record. Billing for interprofessional services is limited to those practitioners who can independently bill Medicaid for evaluation and management services.

SOURCE: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4. p. 6 & 10-11. (June 15, 2020). (Accessed Feb. 2021). 

Member’s record must document consent for Assistive Technology-Remote Monitoring.

SOURCE: MaineCare Benefits Manual, Home and Community Benefits for the Elderly and for Adults with Disabilities, 10-144 Ch. II, Sec. 19, p. 25 (Jan. 7, 2019). (Accessed Feb. 2021). 

Prior to the provision of telemonitoring services, the Health Care Provider shall document that it has provided the member with choice and educational information obtained the member’s written informed consent to the receipt of telemonitoring services. The Health Care Provider shall retain a copy of the signed informed consent in the member’s medical record and provide a copy to the member or the member’s legally authorized representative upon request.

SOURCE:  Mainecare Benefits Manual. Ch. 11. Home Health Services. Sec. 40.08. p. 24. (Aug 1, 2019). (Accessed Feb. 2021).

The originating site must obtain consent from the patient prior to engaging in telehealth and be documented in the medical record. If the participant is unable to provide consent, the medical record must contain in writing an explanation as to why the participant was unable to consent to services rendered via telehealth.

SOURCE: MD Medicaid Telehealth Program. Telehealth Provider Manual. Updated April 2020. p. 1, (Accessed Feb. 2021).

Consent is required unless there is an emergency.

SOURCE: Code of Maryland Admin. Regs. Sec. 10.09.49.05. (Accessed Feb. 2021).

Mental Health

An individual must voluntarily consent to telemental health services, which must be documented in the individual’s medical record.

SOURCE: Code of Maryland Admin. Regs. Sec. 10.21.30.05. (Accessed Feb. 2021).

Health care services provided via telehealth shall conform to the standards of care applicable to the telehealth provider’s profession and specialty. Such services shall conform to applicable federal and state health information privacy and security standards, as well as standards for informed consent.

SOURCE: Massachusetts Senate No. 2984. Section 40 (Accessed Feb. 2021)

No Reference Found

For substance use disorder services, the member must have consented to receiving services over telemedicine.

SOURCE: MN Dept. of Human Svcs., Provider Manual, Substance Use Disorder Telemedicine, Oct. 19, 2017 (Accessed Feb. 2021).

Signed consent for using telehealth is required.

SOURCE: MS Admin. Code 23, Part 225, Rule 1.6(A). (Accessed Feb. 2021).

Prior to the provision of telehealth services in a school, the parent or guardian of the child shall provide authorization for the provision of such service.  Such authorization shall include the ability for the parent or guardian to authorize services via telehealth in the school for the remainder of the school year.

SOURCE: MO Revised Statute. XII Public Health and Welfare. Ch. 208, Sec. 208.677;  MO HealthNet, Rural Health Clinic, p. 166 (Nov. 25, 2020); MO HealthNet, Physician Manual, Telehealth Services, p. 289 (Nov. 25, 2020) & MO HealthNet, Provider Manual, Behavioral Health Services, p. 209 (Nov. 24, 2020). (Accessed Feb. 2021).

No Reference Found

Written or email consent required before initial service delivery. Must include this information:

• A list of alternative care options, including in-person services;
• All existing laws and protections including: confidentiality protections, patient access to all medical information from the consult, and dissemination of client identifiable information;
• Whether the telehealth consultation will be recorded;
• The client shall be informed of all parties present at both ends of the consult, and the client may exclude anyone from either site;
• For each adult client or for a client who is a child but who is not receiving telehealth behavioral health services, a safety plan must be developed, should it be needed at any time during or after the provision of telehealth; Special rules apply for a child who is receiving telehealth behavioral health services;
• Written consent will become part of the client’s medical record and a copy must be provided to the client or authorized representative; and
• If the client is a child or otherwise unable to sign the consent form, the client’s legally authorized representative shall provide the consent.

Sample patient consent form available in Manual Appendix.

SOURCE: NE Admin. Code Title 471 Sec. 1-004.04, Ch. 1, p. 8 & Appendix, 471-000-10 Instructions for Completing NE Medicaid Telehealth Patient Consent Form.  (Accessed Feb. 2021).

Written patient consent is required prior to an initial telehealth consultation. If the patient is a minor, incapacitated, or mentally incompetent such that they are unable to sign the written statement, written consent must be obtained from the patient’s legally authorized representative. Consent is not required in emergency situations.

SOURCE: NE Revised Statutes Sec. 71-8505(2). (Accessed Feb. 2021).

No Reference Found

With written consent of the patient receiving medication assisted treatment through telehealth services provided under this section, the health care provider shall provide notification of the patient’s medication assisted treatment to the doorway, as defined in RSA 167:4-d, II(c), within the region where the patient resides.

SOURCE: NH Revised Statutes Annotated, 167:4-d, (NH HB 1623, 2020 Session), (Accessed Feb. 2021).

Consumers must provide informed consent to participate in any service utilizing telepsychiatry. Should a client choose not to participate, they must be made aware of other face to face options and services. If they choose to participate, the clients must be informed and aware of the location of the psychiatrist/APN providing the telepsychiatry service.

SOURCE: NJ Division of Medical Assistance and Health Services. Newsletter. Vol. 23, No. 21, December 2013. (Accessed Feb. 2021).

Behavioral Health Services

To prescribe medication via telehealth, a prescribing clinician must obtain informed consent, obtain a medical history, and generate a medical record.

SOURCE: NM Human Services Dept. Behavioral Health Policy and Billing Manual for Providers Treating Medicaid Beneficiaries (2019) p. 31 (Accessed Feb. 2021).

Medicaid members must provide consent to participating in services utilizing telehealth. Telehealth sessions/services shall not be recorded without the member’s consent.  Culturally competent translation and/or interpretation services must be provided when the member and distant practitioner do not speak the same language. If the member is receiving ongoing treatment via telehealth, the member must be informed of the following patient rights policies at the initial encounter.  Documentation in the medical record must reflect that the member was made aware of patient rights policies.

SOURCE: NY Dept. of Health, Medicaid Update, Vol. 35, Number 2, February 2019, p. 6-7. (Accessed Feb. 2021).

Mental Health

Part of obtaining approval for telemental health services is obtaining informed consent and may be incorporated into the informed consent process for in-person care.  See regulation for specific requirements.

SOURCE: NY Code of Rules and Regs.  Title 14, Sec. 596.5(b) & 596.6. (Accessed Feb. 2021).

Provider(s) shall obtain and document verbal or written consent. In extenuating circumstances when consent is unable to be obtained, this must be documented.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, p. 6, Nov. 15, 2020. (Accessed Feb. 2021) & NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 8C, Outpatient Behavioral Health Services, p. 7, Jan. 1, 2021. (Accessed Feb. 2021).

Outpatient Behavioral Health

At the time of the initial service, the provider shall obtain the written consent from the legally responsible person for treatment for beneficiaries of all ages.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 8C, Outpatient Behavioral Health Services, p. 15, Jan. 1, 2021. (Accessed Feb. 2021).

No Reference Found

Behavioral Health

Prior to providing services to a client by telehealth, an eligible provider of the service to be provided shall describe to the client the potential risks associated with receiving telehealth services, telehealth and document that the client was provided with the risks and agreed to assume those risks.

SOURCE: OAC 5122-29-31. (Accessed Feb. 2021).

There will be no dissemination of any member images or information to other entities without written consent from the member or member’s parent or legal guardian, if the member is a minor.

In order for OHCA to reimburse medically necessary telehealth services provided to SoonerCare members in a primary or secondary school setting, all of the telehealth requirements must be met, with the exception of the requirement that a parent or legal guardian being there to present the child, as well as all of the requirements shown below, as applicable.

Advance parent or legal guardian consent for telehealth services must be obtained for minors, in accordance with 25 O.S. ” 2004 through 2005.  Additional consent requirements shall apply to school-based services.

For telehealth medical services provided in a primary or secondary school setting, the telehealth practitioner must provide a summary of the service, including, but not limited to, information regarding the exam findings, prescribed or administered medications, and patient instructions, to: (1) The SoonerCare member, if he or she is an adult, or the member’s parent or legal guardian, if the member is a minor; or (2) The SoonerCare member’s primary care provider, if requested by the member or the member’s parent or legal guardian.

Even though physical therapy, occupational therapy, and/or speech and hearing services are not subject to the notification requirements of OAC 317:30-3-27(d)(2), said services must still comply with all other State and Federal Medicaid requirements, in order to be reimbursable by Medicaid.  Accordingly, for those physical therapy, occupational therapy, and/or speech and hearing services that are provided in a primary or secondary school setting, but that are not school-based services (i.e., not provided pursuant to an IEP), providers must adhere to all State and Federal requirements relating to prior authorization and prescription or referral.

SOURCE: OK Admin. Code Sec. 317:30-3-27(c) 9 & (d). (Accessed Feb. 2021).

If the member is a minor, the provider must obtain the prior written consent of the member’s parent or legal guardian to provide services via telehealth, that includes, at a minimum, the name of the provider; the provider’s permanent business office address and telephone number; an explanation of the services to be provided, including the type, frequency, and duration of services. Written consent must be obtained annually, or whenever there is a change in the information in the written consent form, as set forth above. The parent or legal guardian need not attend the telehealth session unless attendance is therapeutically appropriate. The requirements of subsection OAC 317:30-3-27(c)(5), however, do not apply to telehealth services provided in a primary or secondary school setting.  If the member is a minor, the telehealth provider shall notify the parent or legal guardian that a telehealth service was performed on the minor through electronic communication whether a text message or email.

For telehealth medical services provided in a primary or secondary school setting, the telehealth practitioner must provide a summary of the service, including, but not limited to, information regarding the exam findings, prescribed or administered medications, and patient instructions, to:

• The SoonerCare member, if he or she is an adult, or the member’s parent or legal guardian, if the member is a minor; or
• The SoonerCare member’s primary care provider, if requested by the member or the member’s parent or legal guardian.

SOURCE: OK Admin. Code Sec. 317:30-3-27(c)(5) & (d)(2). (Accessed Feb. 2021).

Prior to the delivery of services via a telehealth modality, a patient oral, recorded, or written consent to receive services using a telehealth delivery method shall be obtained and documented annually. Consent must be updated at least annually thereafter.

SOURCE: OR OAR 410-141-3566, Health Systems Division: Medical Assistance Programs, Oregon Health Plan, Telehealth Service and Reimbursement. (Effective Jan. 1, 2021). (Accessed Feb. 2021).

Telehealth services must include patient-clinician agreement of informed consent, discussed with and agreed to by the patient and documented in the medical record.

SOURCE: Oregon Health Authority, Health Evidence Review Commission, Guideline Note Changes for the February 1, 2021 Prioritized List of Health Services, p. C-1. (02/01/21). (Accessed Feb. 2021).

Prior to the delivery of services via a telehealth modality, a patient oral, recorded, or written consent to receive services using a telehealth delivery method in the language that the patient understands must be obtained and documented by Providers annually. Consent must be updated at least annually thereafter. For LEP and Deaf and hard of hearing patients and their families, providers must use qualified and certified health care interpreters when obtaining patient consent.

SOURCE: OR OAR 410-120-1990, Health Systems Division: Medical Assistance Programs, Telehealth. (Effective Jan. 1, 2021). (Accessed Feb. 2021).

Teledentistry

A patient receiving services through teledentistry shall be notified of the right to receive interactive communication with the distant dentist and shall receive an interactive communication with the distant dentist upon request. This must be reflected in the patient’s chart documentation.

SOURCE: OR OAR 410-123-1265, Health Systems Division: Medical Assistance Programs, Oregon Health Plan, Teledentistry. (Effective Jan. 1, 2021). (Accessed Feb. 2021).

School Based Health Services

Providers billing Medicaid for SBHS health related services via telehealth must obtain the child’s/student’s parent or guardian’s written or verbal consent to receive the services via telehealth technologies, prior to the delivery of health-related services to an eligible child/student with disabilities using a telehealth modality. Verbal consent must be documented/noted in the child’s plan of care by the practitioner. Consent must be obtained and documented annually or with change in services on the child/students plan of care.

SOURCE: OR OAR 410-133-0080, Health Systems Division: Medical Assistance Programs, School-Based Health Services, Coverage (Accessed Feb. 2021).

Prior to utilizing telehealth, providers must obtain the consent of the individual to receive services utilizing telehealth. The individual must be informed of all persons who will be present at each end of the transmission and the role of each person. Individuals may refuse services delivered through telehealth. Providers cannot use such refusal as a basis to limit the individual’s access to services delivered face to face.

SOURCE: PA Department of Public Welfare, Medical Assistance Bulletin OMHSAS-20-20, p.3, Feb. 20, 2020, (Accessed Feb. 2021).

No Reference Found

A patient’s written consent is required prior to the dissemination of any of their images or information to other entities.

SOURCE: SC Health and Human Svcs. Dept. Physicians Provider Manual, p. 31 (Feb. 2021) (Accessed Feb. 2021). 

A patient may withdraw from the use of telemedicine at any time.

SOURCE: SC Health and Human Svcs. Dept. Physicians Provider Manual, p. 30 (Feb. 2021) (Accessed Feb. 2021).

No Reference Found

Privacy policies must be reviewed with the individual before beginning a telehealth assessment and the review must be documented in the patient record.  The patient must be informed about privacy policies and given an opportunity to request an in-person assessment before receiving a telehealth assessment.

SOURCE: TN Dept. of Mental Health and Substance Abuse Services. Office of Crisis Services and Suicide Prevention. Minimal Standards of Care.  p. 49-50, (2017) (Accessed Feb. 2021).

The individual being evaluated via telehealth must be informed of the process and given an opportunity to request an in-person face-to-face assessment before conducting a telehealth assessment. This should be documented in his/her record.

Explanation of the process shall include a statement that services will not be withheld if the telehealth encounter is refused and the individual may terminate the telehealth assessment at any time.

Documentation must contain a statement that the telehealth process was explained to the individual and whether or not an objection was raised.

SOURCE: TN Dept. of Mental Health and Substance Abuse Services. Office of Crisis Services Telecommunications Guidelines, p. 8, (2012) (Accessed Feb. 2021).

Written or verbal consent must be obtained to allow any other individual (besides the distant site provider, patient site presenter or representative) to be present during a telemedicine or telehealth visit.

Distant site providers that communicate with clients using electronic communication methods other than phone or facsimile must provide clients with written notification of the physician’s privacy practices prior to evaluation and treatment. Providers must make a “good faith effort” to obtain the client’s written acknowledgment of the notice, including by email response. A distant site provider should provide patients who receive a telemedicine medical service with guidance on the appropriate follow-up care.

The distant site provider must obtain informed consent to treatment from the patient, patient’s parent, or the patient’s guardian prior to rendering a telemedicine medical service.

A parent must provide written or verbal consent to the distant site provider to allow any other individual, other than the health professional as required by Texas Government Code §531.0217(c-4)(4) for school-based telemedicine medical services, to be physically present in the distant or patient site environment during a telemedicine medical service with a child.

SOURCE: TX Medicaid Telecommunication Services Handbook, pg. 5 & 7  (Feb. 2021). (Accessed Feb. 2021).

Additional parental or guardian consent may be required if online or web-based screening tools are used that could result in client data being stored electronically in an outside database other than the provider’s electronic medical record system, or if the data is used for purposes other than THSteps screening. The provider should seek legal advice regarding the need for this consent.

SOURCE:  TX Medicaid Children’s Services Handbook, p. 174, (Feb. 2021), (Accessed Feb. 2021).

If a patient receiving a telemedicine medical service has a primary care physician or provider and consents or, if appropriate, the patient’s parent or legal guardian consents to the notification, the commission shall require that the primary care physician or provider be notified of the telemedicine medical service for the purpose of sharing medical information.  In the case of a service provided to a child in a school-based setting as described by Subsection (c-4), the notification, if any, must include a summary of the service, including exam findings, prescribed or administered medications, and patient instructions.

If a patient receiving a telemedicine medical service in a school-based setting as described by Subsection (c-4) does not have a primary care physician or provider, the commission shall require that the patient’s parent or legal guardian receive:

• The notification required under Subsection (g); and
• A list of primary care physicians or providers from which the patient may select the patient’s primary care physician or provider.

SOURCE: TX Govt. Code Sec. 531.001. (Accessed Feb. 2021).

No Reference Found

A qualified telemedicine and store-and-forward provider must provide appropriate informed consent in a language that the beneficiary understands (see rule for details).

SOURCE: VT Health Care Administrative Rules 13.174.003 (3.101.5), Telehealth, (Accessed Feb. 2021). 

WritTen or oral informed consent for telemedicine services shall be obtained and documented in accordance with Vermont and national policies and guidelines on the appropriate use of telemedicine within the provider’s profession prior to the use of telemedicine.

SOURCE: VT Statutes Annotated, Title 18 Sec. 9361 (2017). (Accessed Feb. 2021).

No Reference Found

Written consent must be obtained for store-and-forward.

SOURCE: WA State Health Care Authority, Medicaid Provider Guide, Physician-Related Svcs./Health Care Professional Svcs., p. 86 (Feb. 2021). (Accessed Feb. 2021).

Member’s consent to receive treatment via Telehealth shall be obtained and may be included in the member’s initial general consent for treatment.  See manual for consent requirements.

SOURCE: WV Dept. of Health and Human Svcs. Medicaid Provider Manual, Chapter–519.17.2 Practitioner Services: Telehealth Services. (Revised Mar. 1, 2020) (Accessed Feb. 2021).

Provider must obtain patient’s (or legal guardian’s) written and verbal consent. The patient has the right to withdraw from telehealth services at any point for an alternative service. See manual for consent requirements.

SOURCE: WV Dept. of Health and Human Svcs., Medicaid Provider Manual, Chapter 523: Targeted Case Management, p. 7 (Jul. 1, 2016); 521.9 Behavioral Health Outpatient Services. P. 9-10. (Jan. 15, 2018). (Accessed Feb. 2021).

Informed consent required.

SOURCE: WI ForwardHealth Online Handbook. Topic #510 Telehealth. (Accessed Feb. 2021).

If the patient and/or legal guardian indicates at any point that he/she wants to stop using the technology, the service should cease immediately and an alternative appointment set up.

The telehealth consent form is no longer required by Wyoming Medicaid. Consent must still be obtained by the provider from the client by one of the following methods:

• Verbally
• Email
• Text Message

This information must be properly documented by the provider and kept on file.

SOURCE: WY Dept. of Public Health Insurance, Medicaid, CMS 1500 ICD-10, p. 116 (Jan. 2021), WY Division of Healthcare Financing Tribal Provider Manual, pg. 115, (Jan. 2021) & Institutional Provider Manual pg. 113.  (Accessed Feb. 2021).