Brandywine Rheumatology may obtain my health information, including my healthcare and prescription history, and provide medical services to me. Brandywine Rheumatology may obtain my insurance coverage information. For purposes of patient identification and clinical documentation, I allow Brandywine Rheumatology to use photographic information taken during a visit to be held securely and confidentially.
I consent to allow Brandywine Rheumatology provide medical services through telehealth communications if appropriate and necessary. This includes both video and audio communications used for telehealth visits. I understand laws protecting patient confidentiality extend to telehealth communications.
I agree that I am financially responsible for services provided to me by Brandywine Rheumatology. I agree that I am responsible for charges not covered by my insurance. I understand, if I am not covered by an insurance carrier, I am considered a self pay patient and financially responsible for services provided.
I request that payment of authorized insurance benefits, including Medicare, if I am a Medicare beneficiary, be made on my behalf to Brandywine Rheumatology, for any medical services provided.
I consent to allow Brandywine Rheumatology contact me by phone, email or text. I consent to allow Brandywine Rheumatology use my email and/or telephone number to communicate with me for purposes of satisfaction surveys, conveying pertinent health information related to my care, visit notifications, billing and collections. I understand I can opt out of any of the above modes of communications at any time.