Allergy and Asthma Center Anita N. Wasan MD PLC
6824 Elm St, Ste 120 Mclean, VA 22101
Tel: 703-992-7065, Fax: 703-992-7063 www.novaallergy.com
TELEMEDICINE PATIENT CONSENT FORM
Telemedicine, according to the Centers for Medicare & Medicaid Services, is "the use of telecommunications and information technology to provide access to health as- sessment, diagnosis, intervention, consultation, supervision and information across distance." There are multiple criteria (video face-to-face consultation, for example) for both patient and provider to fulfill in order for a consultation to be deemed an appropri- ate Telemedicine visit.
We are requesting Allergy and Asthma Center patients acknowledge the following:
1. I understand that all federal and Virginia state laws protecting the privacy and confidentiality of medical information also apply to telemedicine. 2. Video conferencing with your provider will be through the HIPAA compliant telemedicine service provider DOXY.ME. 3. My healthcare provider has explained to me how the video conferencing tech- nology will be used and that the visit may not be the same as a direct patient/ health care provider visit due to the fact that I will not be in the same room as my health care provider. 4. I understand there are potential risks to this technology, including interruptions, unauthorized access and technical difficulties. 5. I understand that my healthcare provider or I can discontinue the telemedicine consult/visit and future telemedicine visits at any time. I understand that with- drawal of my telemedicine consent will not affect my future care nor treatment with this company. 6. I understand that certain procedures such as a complete physical exam, allergy testing, or pulmonary function testing cannot be performed via telemedicine. 7. I understand my health care provider may feel the telemedicine discussion may not be adequate and may request an actual visit to the office for more detailed consultation and examination. If that is so, I will only be charged for the in-office
8. I understand that my insurance may not pay for this telemedicine service, even if my provider feels this is a healthcare treatment option I need. 9. I understand that I will be required to pay the applicable co-pay before the visit occurs. Our staff will do their best to verify that my insurance covers telemedi- cine visits. However, if this visit is deemed as not part of my insurance benefits, I understand that I am responsible for the office cash-price fee of $75 as an al- ready established patient of the practice. If I am a new patient, the cash-price