Introduction

To improve patient care, telehealth involves the use of electronic communications to allow healthcare professionals in various places to communicate specific client information. Providers may include primary care practitioners, specialists, and/or subspecialists. The information may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:

• Client health records
• Live two-way audio and video
• Medical Images
• Output data from health devices and sound and video files

 The usage of electronic systems will include network and software security procedures, as well as steps to safeguard the data and ensure its integrity against malicious or unintentional corruption, in order to protect the confidentiality of client identification and imaging data.

 

Expected Benefits:

• Improved access to care by enabling a client to remain in his/her provider's office (or at a remote site) while the providers obtains test results and consults from practitioners at distant/other sites.
• More efficient client evaluation and management.
• Obtaining expertise of a distant specialist.

 

Possible Risks:

There are potential risks associated with the use of telehealth. These risks include, but may not be limited to:

• In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate decision making by the providers and consultant(s);
• Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment;
• In very rare instances, security protocols could fail, causing a breach of privacy of personal health information;
• In rare cases, a lack of access to complete health records may result in interactions or allergic reactions or other judgment errors;

 

Payment Policy

I acknowledge, understand and agree that:

1. It is my responsibility to check with my insurance company to see if Altmed's services are covered. I will pay for any services that are not covered by my health plan for any reason, or that are covered but applied to a deductible.
2. I will pay any required co-payments, co-insurance, and deductibles, as well as charges for services not covered by insurance, outstanding balances, and delinquent accounts, at the time of service.
3. I assign to Altmed Medical Center all health-care benefits to which I am entitled under any insurance policy or benefit plan, and I authorize payment of those benefits to Altmed directly.
4. If I have health insurance, Altmed will file a claim with my insurer and wait 60 days for a response. If my insurer does not respond within 60 days, Altmed will assume that the visit is not covered and will bill me for the visit charges to the extent permitted by law.
5. By providing Altmed Medical Center with my credit card information and signing up for telehealth services, I (i) authorize Altmed or my insurance provider to charge my credit card for any and all unpaid amounts that they determine to be my responsibility, and (ii) agree to pay all totals charged in accordance with this consent and authorization in accordance with the issuing bank cardholder agreement. At the conclusion of my telehealth session or at a later time, Altmed may charge such sums to my credit card, and I thus consent to such use.
6. I agree to pay any outstanding bills that Altmed Medical Center or my insurance company determines to be my obligation in full and will be billed for all such accounts. In addition to a $30 cost for returned checks, Altmed will impose late fees of 1.5% per month on unpaid accounts beginning 30 days after the first statement. I am liable for a $40 collections fee and all related legal costs in addition to the amount outstanding when delinquent accounts are turned over to a collection agency.
7. If my account is past due, Altmed Medical Center has the right to refuse non-emergency treatment.

 

By signing this form, I understand the following:

1. I understand that the laws that protect privacy and the confidentiality of health information also apply to telehealth, and that no information obtained in the use of telehealth which identifies me will be disclosed to researchers or other entities without my consent.
2. I understand that I have the right to withhold or withdraw my consent to the use of telehealth during my care at any time, without affecting my right to future care or treatment.
3. I understand that I have the right to inspect all information obtained and recorded during a telehealth interaction and may receive copies of this information for a reasonable fee.
4. I understand that a variety of alternative methods of health care may be available to me, and that I may choose one or more of these at any time. My provider has explained the alternatives to my satisfaction.
5. I understand that telehealth may involve electronic communication of my personal health information to other practitioners who may be in other areas, including out of state.
6. I understand that it is my duty to inform my provider of electronic interactions regarding my care that I may have with other healthcare providers.
7. I understand that I may expect the anticipated benefits from the use of telehealth in my care, but that no results can be guaranteed or assured.

I, {name}, have read and understand the information provided above regarding telehealth, have discussed it with my provider or such assistants as may be designated, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telehealth in my care.