Telehealth Appointment Consent

Patient's Name*

First NameLast Name

Patient's Date of Birth*

Date

Email Address*

example@example.com

Phone Number*

Area CodePhone Number

Telehealth Appointment Consent

1. I understand that Advanced Specialty Care, PC, has recommended to me that I engage in a telehealth appointment with one or more of their health care providers.

2. Advanced Specialty Care, PC has explained to me how the telehealth technology will be used to connect me with a provider. Telehealth appointments may be conducted by videoconferencing, video images, still (high quality photo) images, or by telephone conference. I understand that this appointment will not be the same as a direct patient/health care provider visit due to the fact that I will not be in the same room as my health care provider. For Plastic/Cosmetic surgery patients all recommendations done via videoconferencing are preliminary pending an in office evaluation.

3. I understand there are potential risks to this technology, including interruptions, unauthorized access and technical difficulties. I understand that my health care provider or I can discontinue the telehealth appointment if it is felt that the videoconferencing connections are not adequate for the situation. I understand that I can discontinue the telehealth appointment at any time

4. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Others may also be present during the appointment other than my specialty health care provider in order to operate the equipment, or obtain medical information. All of our healthcare providers will maintain confidentiality of the information obtained. I further understand that I will be informed of their presence during the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/physical examination that are personally sensitive to me; (2) ask non-medical personnel to leave the telehealth examination room; and/or (3) terminate the telehealth appointment at any time.

5. I have been given an opportunity for an office visit, and in choosing to participate in a telehealth appointment, I understand that some parts of the examination will not be feasible via telehealth and this may impact healthcare decisions. After my telehealth visit if I wish an office visit it will be arranged to follow.

6. In an emergency situation, I understand that the responsibility of the telehealth specialist or provider may be to direct me to emergency medical services, such as emergency room. Or the telehealth provider may discuss with and advise my local provider. The telehealth specialist’s or provider’s responsibility will end upon the termination of the telehealth connection.

7. I understand that billing for the telehealth consultation will occur from Advanced Specialty Care, PC, and if covered by insurance will be processed accordingly. If the insurance deems this to be a non-covered service the standard fee of $175 for new patient or $95 for established patient will be your responsibility.

8. I have read this document carefully, and understand the risks and benefits of the telehealth appointment and have had my questions regarding the procedure explained and I hereby consent to participate in a telehealth appointment visit under the terms described herein.

Please Check*

I have read this document carefully, and understand the risks and benefits of the telehealth appointment and have had my questions regarding the procedure explained and I hereby consent to participate in a telehealth appointment visit under the terms described herein.

Patient/Guardian Signature*

Please click in the signature box and hold to draw/sign your signature.

Patient/Guardian Name (Please Type)*

Type Patient/Guardian Full Name Here

Date & Time Signed*

DateHourMinutesAM/PM Option