If you prefer a printable pdf of this document, please click here. Once complete, you may fax to 301-493-5532 or email to info@bethesdamed.com.
Otherwise, to submit a secure, HIPAA compliant electronic version, please proceed to the form below.
“Virtual” or “telehealth” visits refer to being evaluated and treated by your health care provider via electronic communication while you and your treating provider are in different locations. Examples of the virtual services offered pursuant to this consent include:
I understand there may be limitations and/or special conditions relating to virtual or telehealth visits including: