PLEASE NOTE: THE PARENT OR LEGAL GUARDIAN OF THE MINOR CHILD / PATIENT, MUST BE PRESENT AT THE FIRST APPOINTMENT.
This form is required to allow us to evaluate, treat, and bill for medical goods and services provided to a minor. In the event of my absence, I consent to having American Skin Institute conduct examinations and perform procedures as are medically required and administer treatment and medication as deemed necessary and/or advisable to the minor child/patient noted above.
Primary insurance: Insurance Company Name Member ID: # Subscriber information (If different from patient):Name Relationship Birthdate
Secondary insurance: Insurance Company Name Member ID: # Subscriber information (If different from patient):Name Relationship Birthdate
1. PURPOSE: The purpose of this form is to obtain your consent for a telemedicine consultation with a physician and/or healthcare provider. The purpose of this consultation is to assist in the diagnosis or treatment of your dermatology related condition.
2. NATURE OF TELEMEDICINE CONSULTATION: Telemedicine involves the use of audio, video or other electronic communications to interact with you, consult with your healthcare provider and/or review your medical information for the purpose of diagnosis, therapy, follow-up and/or education. During your telemedicine consultation, details of your medical history and personal health information may be discussed with other health professionals through the use of interactive video, audio and telecommunication technology. Additionally, a physical examination of you may take place and video, audio, and/or photo recordings may be taken. Additionally, non-medical technical personnel may participate in the telemedicine consultation to aid in the audio/video link with the physician.
3. RISKS, BENEFITS AND ALTERNATIVES: The benefits of telemedicine include having access to medical specialists and additional medical information and education without having to travel outside of your local health care community. A potential risk of telemedicine is that because of your specific medical condition, or due to technical problems, a face-to-face consultation still may be necessary after the telemedicine appointment. Additionally, in rare circumstances, security protocols could fail causing a breach of patient privacy. The alternative to telemedicine consultation is a face-to-face visit with a physician.
4. MEDICAL INFORMATION AND RECORDS: All laws concerning patient access to medical records and copies of medical records apply to telemedicine. Dissemination of any patient identifiable images or information from the telemedicine consultation to researchers or other entities shall not occur without your consent.
5. CONFIDENTIALITY: All existing confidentiality protections under federal and California law apply to information used or disclosed during your telemedicine consultation.
6. RIGHTS: You may withhold or withdraw your consent to a telemedicine consultation at any time before and/or during the consult without affecting your right to future care or treatment, or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled. If you are a Medi-Cal recipient and receiving teleophthalmology or teledermatology by store and forward, you have the right to interactive communication with the physician. This communication may occur at the time of your consultation or within 30 days after you receive the results of the consultation.
My health care provider has discussed with me the information provided above. I have had an opportunity to ask questions about this information and all of my questions have been answered. I have read and agreed to a telemedicine consultation.
As required by HIPAA of 1996, you have the right to request that communication concerning your personal health information, be made through confidential channels. American Skin Institute will make reasonable efforts to accomodate all reasonable requests. Some method of contact must be provided in order to contact you with the results from labortory tests, biopsies, treatment recommendations, and payments.
I hereby request the use of the following communication channels for information related to my personal health, treatment, or payment for treatment. This request supersedes any prior request for confindential communications I have made.
Pursuant to Assembly Bill (AB) 1278, we are required to provide a notice to our patients regarding the Open Payments database (Database), which is managed by the U.S. Centers for Medicare & Medicaid Services, or CMS. I certify that I have received this written notice. The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov. For informational purposes only, a link to the federal Centers for Medicare and Medicaid Services (CMS) Open Payments web page is provided here. The federal Physician Payments Sunshine Act requires that detailed information about payment and other payments of value worth over ten dollars ($10) from manufacturers of drugs, medical devices, and biologics to physicians and teaching hospitals be made available to the public.
Thank you for choosing American Skin Institute to be your healthcare provider. Our team of medical professionals will strive to ensure the best possible outcomes for your care. Please take the time to review our financial policies below; this information is compiled with the intent to provide you comprehensive understanding of all the financial events that could impact your visit.
I authorize the American Skin Institute to conduct examinations, and perform procedures as are medically required to administer treatment and medication as deemed necessary or advisable.
American Skin Institute is hereby authorized to release a complete report of services rendered, diagnosis, findings, and details of treatment and progress for the purpose of receiving payment for such services rendered. Recipients of such information may include: authorized billing agents, insurance carriers, employer's worker's compensation insurance company, other third party payers, the Social Security Administration under Title XVII (18) of the Social Security Act, Professional Review Organizations, or other Intermediaries responsible for payment of services rendered. The release of information consent may be revoked at any time by giving written notice.
If release of information is refused, the patient will be held responsible for payment of all charges for services rendered. In consideration of medical goods and services provided by the American Skin Institute, I give all rights, title, and interest to the medical/surgical/supply reimbursement in accordance with the terms and benefits of the patient's insurance policy or other health benefits including Medicare Part B. I remain fully responsible for payment of any and all charges not covered by insurance or Medicare.