I verify that above is my correct legal name. I give consent to Telemedora, PC to give me medical treatment.
 
I allow Telemedora, PC to file for insurance benefits to pay for the care I receive.
                 
I understand that:
 
·       Telemedora, PC will have to send my medical record information to my insurance company.
·       I must pay my share of the costs.
·       I must pay for the cost of these services if my insurance does not pay or I do not have insurance.
·       I have the right to refuse any procedure or treatment. 
·       I have the right to discuss the risks and benefits of all procedures and treatment proposed by my health care provider(s), together with any available alternatives.
·       Telemedora, PC will provide care consistent with the prevailing standards of medical practice but makes no assurances or guarantees as to the results of treatment.
·       Before prescribing any controlled substance to me, Telemedora, PC may review information from the Prescription Drug Monitoring Program in my state of residence regarding my prior receipt of controlled substances.
·       I have the right to review and receive copies of my medical records, including all information obtained during a telehealth interaction, subject to Telemedora’s standard policies regarding request and receipt of medical records and applicable law.
·       The laws of the state in which I am located will apply to my receipt of telehealth services.
 
I CONSENT TO, UNDERSTAND AND AGREE TO ALL THAT IS STATED ABOVE.