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Consent Form


Myles Home Health Agency, is moving to streamline and simplify its method of documentation. Electronic signatures are a method of reducing paperwork and streamlining the collection of information. Most payers in the healthcare field (Long term care insurance, Medicaid, VA, and Federal programs) require a signature for documentation of delivered services, surveys, and contracts. The purpose of this consent is to ensure that you are fully aware of your rights and responsibilities of agreeing to receive and sign documents electronically. This Agreement governs the rights, duties, and responsibilities of “Client” in the use of an electronic (written or verbal) signature with Myles Home Health Agency.

  1. Consent: You have a choice. You do not have to participate in electronic signing of documents. We may continue with the use of paper documentation if preferred.
  2. You will be given sufficient opportunity to review any document for completeness and accuracy prior to electronically signing the document.
  3. Once you affix your electronic signature to a document, the document will not be altered in any way.
  4. In addition to written electronic signatures, this consent also authorizes my verbal approval of records associated with my care through the Myles Home Health Agency telephony system.
  5. You have the right to have any document provided in paper or non-electronic form. A paper copy of any electronically signed document can be provided upon request at no charge.
  6. Hardware/Software Requirements: To access data immediately for daily logs, you must have internet access, an email account, and have account set up with Myles Home Health Agency to access the family room.
  7. Ability to use software to access information: You may request a demonstration of how to access your information, request paper copies, or request email copies of documentation.
  8. You have the right to withdraw or change your consent to sign electronic documents with electronic signature at any time. The legal validity and enforceability of the electronic documents, signatures, and deliveries used prior to formal withdrawal of consent will not be affected. In other words, all prior electronic signatures shall be fully valid and enforceable. You may change your acceptance or denial of this request by contacting Myles Home Health Agency by email at info(at)myleshomehealthagency(dotted)com, by phone at 252.206.1112, or in person, during normal business hours, at 3102 Nash St N, Wilson, NC 27896.
  9. You will be notified in writing if the details of this request changes.
  10. It is your responsibility to protect your electronic signature and immediately request that your electronic signature be revoked if you discover or suspect that it has been or is in danger of being lost, disclosed, compromised, or subjected to unauthorized use in any way.

By signing this consent form, Client is providing consent to the use of electronic and verbal signatures to establish Client’s identity and sign electronic documents and forms associated with the provision of care by Myles Home Health Agency. Client further agrees that, for the purposes of authorizing and authenticating electronic health records, Client’s electronic signature or verbal approval has the full force and effect of a signature affixed by hand to a paper document.