Altitude prophylaxis telehealth visit

Telemedicine and Consent Form
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age:*
Name if signed by other than the patient

First NameLast Name
Relationship to the patient
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Age:*
Gender:*

FemaleMale
First day of last menstrual period if applicable:

MonthDayYear
Date
Pregnant

YesNoMaybe
Will you being staying in Summit County for travel?

YesNo
If so will you require oxygen rental?

YesNoMaybe
Hotel if applicable:
Room #:
Address of place of lodging including room # (if applicable) if not listed above

Address and room number (if applicable)

CityState

Zip Code
Date of arrival:

MonthDayYear
Date leaving:

MonthDayYear
Pharmacy name:*
Pharmacy Zip Code:*
Pharmacy Phone Number:*
Please enter a valid phone number.
Allergies to Medications?*

NoneYes (Please List)
Medication Allergies and reaction:
Current Medications*

NoneYes (Please List)
Medication List:
Past or Present Medical Conditions:*

No medical conditionsHeart problemsLung problemsDiabetesPrior Covid infectionHigh Blood PressureHistory of Altitude SicknessThyroid diseaseHistory of High-Altitude Pulmonary EdemaOther (Please List)
Other Medical conditions: (please list / describe)
Surgeries*

NoneYes (please list)
Surgeries (Please list):
Family Medical History*

NoneYes (please list)
Family Medical History (please list/describe):
Introduction to Telehealth

Telehealth is healthcare provided by any means other than a face-to-face visit. In telehealth services, medical and mental health information is used for diagnosis, consultation, treatment, therapy, follow-up, and education. Health information is exchanged interactively from one site to another through electronic communications. Telephone consultation, videoconferencing, transmission of still images, e-health technologies, patient portals, and remote patient monitoring are all considered telehealth services.
CONSENT FOR TELEHEALTH CONSULTATION

1.     I understand that I am voluntarily engaging in a telemedicine consultation with HIGH ALTITUDE MOBILE PHYSICIANS

2.     I understand that the video conferencing technology and/or phone consultations will 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.

3.     I understand that a telehealth consultation has potential benefits including easier access to care, decreasing costs, and allowing visits to be performed from the comfort of my home.

4.     I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.

5.     I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. I understand that if there is another individual present during the telehealth consultation that I will be informed of their presence and I will also disclose if there is another individual with myself. It is agreed that these individuals will maintain confidentiality of the information obtained. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/physical examination that are personally sensitive to me; (2) ask non‐medical personnel to leave the telemedicine examination room: and or (3) terminate the consultation at any time.

6.     I understand that the alternative to a telemedicine consultation is to forgo evaluation and treatment with HIGH ALTITUDE MOBILE PHYSICIANS and to seek out an in-person evaluation elsewhere. Thus, I am freely choosing to participate in a telemedicine consultation.

7.     I understand that telemedicine has limitations in regard to the physical examination. I understand that the physical exam portion of the care provided through HIGH ALTITUDE MOBILE PHYSICIANS will be limited to inspection via video conferencing and some parts of the exam such as physical tests, examination of certain body parts, and vital signs may be conducted by individuals at my location at the direction of the consulting health care provider or not done at all.

8.     Telemedicine services offered through HIGH ALTITUDE MOBILE PHYSICIANS are not an Emergency Service and in the event of an emergency or urgent medical issue, I will use a phone to call 911, go to the emergency department, or go to an urgent care.

9.     To maintain my privacy, I will not share telemedicine login information or video conferencing links with anyone unauthorized to attend the appointment.

By signing this form, I certify:

·       That I have read or had this form explained/read to me and I understand its contents including the risks and benefits of telemedicine.

·       That I have had the opportunity to ask questions and have had them answered to my satisfaction.

BY SIGNING BELOW, I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.

{patientName}

{dateOf}

Must be signed by legal guardian if patient is under age 18 or requires a legal guardian:

{legalGuardian}
Please sign:*

Clear
My medical information may be shared with (ie: spouse, parent, provider etc):
Introduction

Telehealth is healthcare provided by any means other than a face-to-face visit. In telehealth services, medical and mental health information is used for diagnosis, consultation, treatment, therapy, follow-up, and education. Health information is exchanged interactively from one site to another through electronic communications. Telephone consultation, videoconferencing, transmission of still images, e-health technologies, patient portals, and remote patient monitoring are all considered telehealth services.
Please check that you understand all of the following:

I understand that telehealth involves the communication of my medical/mental health information in an electronic or technology-assisted format.I understand that I may opt out of the telehealth visit at any time without loss or withdrawal of treatment.I understand that telehealth services can only be provided to patients, including myself, who are residing in the state of Colorado at the time of this service.I understand that all electronic medical communications carry some level of risk. While the likelihood of risks associated with the use of telehealth in a secure environment is reduced, the risks are nonetheless real and important to understand. These risks include but are not limited to: •It is easier for electronic communication to be forwarded, intercepted, or even changed without my knowledge and despite taking reasonable measures. •Electronic systems that are accessed by employers, friends, or others are not secure and should be avoided. It is important for me to use a secure network. •Despite reasonable efforts on the part of my healthcare provider, the transmission of medical information could be disrupted or distorted by technical failures.I agree that information exchanged during my telehealth visit will bemaintained by the healthcare providers,and healthcare facilities involved in my care.I understand that medical information, including medical records, are governed by federal and state laws that apply to telehealth. This includes my right to access my own medical records (and copies of medical records).I understand that I must take reasonable steps to protect myself fromunauthorized use of my electronic communications by others.The healthcare provider is not responsible for breaches of confidentiality caused by an independent third party or by me.I agree that I have verified to my healthcare provider my identity and current location in connection with the telehealth services. I acknowledge that failure to comply with these procedures may terminate the telehealth visit.I understand that I have a responsibility to verify the identity and credentialsof the healthcare provider rendering my care via telehealth and to confirm thathe or she is my healthcare provider.I understand and agree that a medical evaluation via telehealth may limit my healthcare provider’s ability to fully diagnose a condition or disease. As the patient, I agree to accept responsibility for following my healthcare provider’s recommendations—including further diagnostic testing, such as lab testing, a biopsy, or an in-office visit.By signing below, I understand the inherent risks of errors or deficiencies in theelectronic transmission of health information and images during a telehealth visit.I understand that there is never a warranty or guarantee as to a particularresult or outcome related to a condition or diagnosis when medical care isprovided.To the extent permitted by law, I agree to waive and release my healthcare provider and his or her institution or practice from any claims I may have about the telehealth visitI understand that electronic communication should never be used for emergency communications or urgent requests. Emergency communications should be made to the provider’s office or to the existing emergency 911 services in my community.NOTICE OF PRIVACY PRACTICES I acknowledge that I have been offered a copy of the practice’s Notice of Privacy Practices, which describes the ways in which the practice may use and disclose my healthcare information for its treatment, payment, healthcare operations and other described and permitted uses and disclosures. I understand that I may contact the Office Manager if I have a question or complaint. I understand that this information may be disclosed electronically by the Provider and/or the Provider’s business associates. To the extent permitted by law, I consent to the use and disclosure of my information for the purposes described in the practice’s Notice of Privacy Practices.RELEASE OF INFORMATION I hereby permit the medical providers or other health professionals involved in the outpatient care to release healthcare information for purposes of treatment, or healthcare operations.CONSENT TO EMAIL OR TEXT USAGE HEALTHCARE COMMUNICATIONS I consent to receive text messages from the practice at my cell phone and any number forwarded or transferred to that number AND/OR emails to receive communication. I understand that security of information sent, cannot be guaranteed. The practice does not charge for this service, but standard text messaging rates may apply as provided in your wireless plan (contact your carrier for pricing plans and details). Revocation of the permission to use text and/or email may be done in writing at any time.I, , agree and understand that by signing the Electronic Signature Acknowledgment and Consent Form, that all electronic signatures are the legal equivalent of my manual/handwritten signature and I consent to be legally bound to this agreement.
Notice of Privacy Practices
I certify that I have read and understand this agreement:

Clear
MEDICARE OPT OUT PRIVATE CONTRACT

• I, Leslie Shook and Danielle Shook (High Altitude Mobile Physicians), have been excluded from Medicare under §§1128, 1156 or 1892 of the Act.
• I, the beneficiary or the beneficiary’s legal representative accepts full responsibility for payment of the physician’s or practitioner’s charge for all services furnished by the physician/practitioner.
• I, the beneficiary or the beneficiary’s legal representative understands that Medicare limits do not apply to what the physician/practitioner may charge for items or services furnished by the physician/practitioner.
• I, the beneficiary or the beneficiary’s legal representative agrees not to submit a claim to Medicare or to ask the physician/practitioner to submit a claim to Medicare.
• I, the beneficiary or the beneficiary’s legal representative understands that Medicare payment will not be made for any items or services furnished by the physician/practitioner that would have otherwise been covered by Medicare if there was no private contract and a proper Medicare claim had been submitted.
• I, the beneficiary or the beneficiary’s legal representative enters into the contract with the knowledge that the beneficiary has the right to obtain Medicare covered items and services from physicians and practitioners who have not opted out of Medicare, and that the beneficiary is not compelled to enter into private contracts that apply to other Medicare-covered services furnished by other physicians or practitioners who have not opted out.
• The expected or known effective date and expected or known expiration date of the opt-out period is April 1, 2018 through April 1, 2026.
• I, the beneficiary or the beneficiary’s legal representative understands that Medigap plans do not, and that other supplemental plans may elect not to, make payments for items and services not paid for by Medicare.
• This contract cannot be entered into by the beneficiary or by the beneficiary’s legal representative during a time when the beneficiary requires emergency care services or urgent care services. (However, a physician/practitioner may furnish emergency or urgent care services to a Medicare beneficiary in accordance with §40.28;)
• I, the beneficiary or the beneficiary’s legal representative will receive or have received a copy (a photocopy permissible) of this contract, before items or services are furnished to me under the terms of this contract.
Patient Signature:

Clear
YOUR PROVIDER WILL COMPLETE THE SECTION BELOW.

PLEASE CLICK ON SUBMIT NOW.
Provider note
RX:

Diamox 125mg po bid x 5 days starting 24 hours prior to ascentO2 prophylaxis
Plan:
Location of Service:
Date of arrival:

MonthDayYear
Date
Date leaving:

MonthDayYear
Date
Oxygen RX
Oxygen concentrator L/min via cannula, continuous while sleeping. As needed while awake.
Provider Name and NPI#
Provider signature:

Clear
Date of concentrator rental:

MonthDayYear

Hour MinutesAM/PM Option
O2 sat on room air:
HR on room air:
Concentrator #:
Conc. P/U Date:

MonthDayYear
Date
Concentrator #:
Conc. P/U Date:

MonthDayYear
Date
ICD-10 Diagnosis Code
Other ICD-10 Code:
Charges:
prevnext( X )
99203 - Office visit for new patient (telehealth) modifier 95 ; POS (11)
$45.00



E1390-Oxygen Concentrator Rental (modifiers: RR & QF)
$150.00



Oxygen concentrator rental 2
$150.00



Oxygen splittersplitter, straight tubing and extra cannula
$15.00 Quantity



Oxygen cannulasplitter, straight tubing and extra cannula
$5.00 Quantity



Oxygen CPAP adapterCPAP adapter and straight tubing
$10.00 Quantity



Total

$0.00
Other:
Other Amount $:
Total:
Should be Empty:

Telemedicine and Consent Form

Provider note