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  • If you are interested in urgent virtual care or an in-person house call, please complete this form.  If you are outside the 10 mile radius, or outside business hours, please confirm availability before booking online.

    Please read this Financial Agreement for The Hourly Plan and sign below.

    The Plan. The Hourly Plan is ideal for Urgent Care, Telemedicine or Virtual Consultations, or may serve as a Gift Consultation for Family and Friends, as well as for prospective patients considering changing physicians.  This Plan is suitable for a one-time episodic consultation when your primary care physician is not available, or for a second opinion.

    The Concierge Practice. The Hourly Plan allows for non members to receive medical care.  As a concierge practice, Marta Long MD (MLMD) does not provide primary care to non members.  The Hourly Plan excludes primary care. MLMD understands that a one-time consultation may be required for certain medically complex situations for patients who desire more attention to their symptoms, who are home-bound, or who require the expertise provided by Dr. Long.

    The Pricing. Pricing for the Hourly Plan medical care is $400/hour.  You understand and agree to pay the Hourly Plan fee by credit card and be billed for the time spent with the physician.  This includes the time spent in telephone or video calls at the hourly rate of $400/hour. Time is rounded up to the nearest 5th minute, for example 60 minutes is $400, 30 minutes is $200, 15 min is $100, 10 min is $67 and 5 min is $33. The typical duration of service for an Urgent Care Consultation is 30 minutes, House Call is 1 hour, and Consultative Medicine 2-3 hours.

    Membership. If you are offered Concierge Membership, your Hourly payment may be applied to the Yearly Retainer fee ($4800).  You otherwise agree to follow up with your primary care doctor within the next business day, and the Hourly Consultation is considered a Second Opinion Consultation for non members. MLMD will make every effort to communicate with your primary physician regarding the Second Opinion findings, diagnosis and treatment recommendations on your behalf to facilitate the followup care.

    Limitations. Under no circumstances will emergency care be provided.  If you have an emergency, call 911.  If you decline to become a Member, you will receive medical supervision, when medically necessary, at the hourly rate, for a period up to 24 hours after the initial evaluation which includes all telephone calls.  MLMD is not obligated to continue care beyond 24 hours, nor beyond the initial consultation.

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  • Virtual Appointment

    Request the virtual appointment date and time that works well for you. If you want an appointment time that is not available, please mention in the paragraph above where you also share the reason for seeking medical care (for example, "I'd like the next available urgent appointment").
  • House Call Appointment

    Request the House Call appointment date and time that works well for you. If you want an appointment time that is not available, please mention in the paragraph above where you also share the reason for seeking medical care (for example, "I'd like the next available urgent appointment").
  • prev next ( X )
    30 minute Telephone or Video Consultation with Dr. Long Available 6am to midnight for nonmembers. You may submit this form 24/7 and Dr. Long will call you at the next available appointment between 6am to midnight.
    $ 200.00
       
    60 minute House Call with Dr. Long Available 9am to 12noon for nonmembers. You may submit this form 24/7 and Dr. Long will see you within the next 24 hours.
    $ 400.00
       
    Total
    $ 0.00

    Credit Card Details
  • Marta Long MD, Inc

    19712 MacArthur Blvd Ste 110, Irvine, CA 92612

    Irvine P.O. Box 63524 Irvine CA 92602. 

    If you have any questions, call 949-237-2949.

  • Informed Consent for TeleHealth Consultations


    “Telehealth” means that I may be evaluated and treated by a Physician from a distant location via electronic communication. The information may be used for diagnosis, therapy, follow-up, and/or education, and may include any of the following: patient medical records, medical images, live two-way audio and video, and/or output data from medical devices and sound and video files. Since this may be different than the type of consultation with which I am familiar, it is important that I understand and agree to the following statements:

    ● The consulting physician will be at a different location from me.

    ● I understand that my voice and image may be recorded in order to assist the medical or registration personnel and I consent to any such audio and video recording.

    ● I understand there are potential risks to this technology, including, but not limited to, interruptions, unauthorized access, technical difficulties, and call termination. I understand that there are alternatives and limitations to this type of care. I understand that my healthcare provider or I can discontinue the telemedicine consultation/visit if it is felt that the video conferencing connections are not adequate for my situation.


    ● I understand that I may be released before all my medical problems are known or treated and it is my responsibility to make such conditions or symptoms known to the medical personnel as well as to make arrangements for follow-up care.


    ● I understand that payment will be collected at the time of service unless my insurance has agreed to make a special consideration to cover Telehealth Services. I also understand that I may be responsible for Telehealth Services if all or some of my consultation is not covered by my insurance.

    Authorizations

    The undersigned patient, or authorized individual acting on behalf of the patient, understands and agrees as follows:

    ● By signing below, I am granting permission to Marta Long MD to perform and administer care and treatment of the patient via Telehealth.

    ● Grants permission to release to third party payers (such as Medicare, private insurance companies) and their representatives, and/or other physicians involved in the patient's care, any information needed in connection with all care
    rendered to the patient.


    ● If the patient is under the age of 18 or lacks capacity, the signing party affirms that they are either the parent or legal guardian of such patient and has full legal authority to seek medical assistance on behalf of the patient.

    Financial responsibilities
    I agreed to pay, in a timely manner, for Telehealth Services provided. I authorize payments directly to Marta Long MD for all benefits payable. I understand that most private and government interests do not include coverage for the service as a “Covered Service”. I understand that I am responsible for any unpaid bills not covered by Medicare and any other private insurance company.

    Signature
    __________________________ 

    Date

    __________________________

  • Patient Privacy Information (HIPAA)

    NOTICE OF PRIVACY PRACTICES


    Basically, except for disclosure of information required by law or for billing purposes or patient management nothing can be disclosed without the signature of the patient as well as the signature of the attending physician and the information transfer will take at least 1 day to complete and transferred by mail unless you request in writing an alternative method.

    Signatures must be in writing on regular paper and electronic options including faxes and e-mail are not acceptable. For release of your information by our office, paper copies of a signature are as valid as the original. The notice below will explain how we may use and disclose your medical information, our obligations related to the use and disclosure of your medical information, and your rights related to any medical information that we have about you. This notice applies to the medical records that are generated in or by our office. Please direct questions to our Privacy Site Coordinator: Marta Long, via phone 949-237-2949 or at our office address.


    With a few exceptions, we are required to obtain your authorization for the use or disclosure of the information. We have listed some of the reasons why we might use or disclose your medical information and some examples of the types of uses and disclosures below. Not every use or disclosure is covered. In addition to the office, the following persons will also follow the practices described in this Notice of Privacy Practices: Any health care professional who is authorized to enter information in your medical record. In addition, they may share medical
    information for treatment, payment or healthcare operations as they are described in this Notice of Privacy Practices.


    Use and Disclosure of Medical Information: We can use or disclose medical information about you regarding your treatment, payment for services, or for healthcare operations. We may also disclose your protected health care information for the treatment activities of another provider, the payment activities of another provider or covered entity, and certain limited healthcare operations of another covered entity.

    For Treatment: To provide you with medical treatment or services, we may need to use or disclose information about you to doctors, nurses, technicians, or other healthcare personnel who are involved in your treatment. For example, a doctor
    may need to know what drugs you are allergic to before prescribing medications. We may also disclose medical information about you to people who may be involved in your medical care after you leave the office such as home health agencies, your family, a friend, Hospice employees, long term care facilities, and, if you request, your clergy member.

    For Payment: We may use and disclose your medical information to bill and receive payment for the treatment that you receive here. We may also ask your insurance company for prior approval for a service to determine whether the insurance company will pay for the service.

    Uses and Disclosures of Medical Information that do not require your authorization: We can use or disclose health information about you without your authorization when there is a potential emergency, when we are required by law or statute, or when there are substantial communication barriers to obtaining authorization from you.

    Further, we may disclose your health information without your authorization in any of the following circumstances: When necessary to contact you to provide:
    appointment notices, simple messages left noting test results OK, simple generic or routine management instructions delivered by e-mail or voice mail as a reply to your e-mail or voice mail or recent health management, when it is required by law, or required by regulations or statutes for public health activities, such as mandated disease reporting, etc., When reporting information about victims of abuse, neglect or domestic violence; When disclosing information for the purpose of health oversight activities, such as audits, investigations, licensure or actions or legal proceedings or actions and activity with a pharmacy relating to your potential medication. When disclosing information for law enforcement purposes, for instance, to locate or identify a suspect, fugitive, witness or missing person or regarding a victim of a crime who can not give authorization because of incapacity; When disclosing information about deceased persons to medical examiners, coroners and funeral directors; When disclosing or using information for organ and tissue donation purposes; When we believe in good faith that the disclosure is necessary to avert a serious health or safety threat to you or to the public's safety;

    Disclosures or to which you may object: We will use or disclose your health information for any of the purposes described in the above section unless you affirmatively object to or otherwise restrict a particular release. You must direct your written objections or restrictions to the Privacy Site Coordinator who is Marta Long at our office address.

    Other Uses and Disclosures: We will not use or disclose your health information without your written authorization except as described in this Notice of Privacy Practices. If you provide us with written authorization to use or disclose information, you can change your mind and revoke your authorization at any time, as long as it is in writing. If you revoke your authorization, we will no longer use or disclose the information. However, we will not be able to take back any disclosures that we have made pursuant to your previous authorization.


    Your Health Information Rights: Although your health record is the property of our office, you have the right to: Request Restrictions: You have the right to request that we restrict any use or disclosure of your health information. We are not required to agree to any restriction that you request. If we do agree to adhere to your restrictions, we will comply with your request unless the information is needed to provide you treatment. Any request to restrict uses or disclosures must be made in writing to the Privacy Site Coordinator or the Our office Corporate Privacy Officer. Your request must indicate: (1) what information you want limited; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply. Receive Information in Certain Form and Location: You have the right to receive information about your health in a certain form and location. For instance, you can request that we contact you at work. To request confidential communications, you must make your request in writing to the Privacy Site Coordinator The request must tell us how and/or where you want to receive information. We will attempt to accommodate reasonable requests. Inspect and Copy your Protected Health Information: You have the right to inspect and request a copy of your protected health information that may be used to make decisions about your care, with the exception of psychotherapy notes. If you want to see or copy your medical information, you must submit your request in writing to the office Privacy Officer. If you request copies of information, we may charge the standard fee for any costs associated with your request, including the cost of copies, mailing, or other supplies as set by California statutes and regulations.


    *** NOTE: We can deny your request if it is not in writing and if it does not include why the information should be changed. We can also deny your request for the following reasons: (1) the information was not created by our office or unless the person or entity that did create the information is no longer available; (2) the information is not part of the medical record kept by or for our office, or (3) the information is not part of the medical record that you would be permitted to inspect and copy; or (4) we believe the information is accurate and complete.
    Complaints: If you believe that we have violated any of your privacy rights or have not adhered to the information contained in this Notice of Privacy Practices, you can file a complaint by putting it in writing and sending it to the office or Privacy Site Coordinator. You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services, 200 Independence Avenue, S.W., Washington, D.C. 20201. To acquire a copy of the complaint form from the Office of Civil Rights please call 1-(800)-368-1019.


    Changes To This Notice of Privacy Practices: We reserve the right to change or modify the information contained in this Notice of Privacy Practices. Any changes that we can make can be effective for any health information that we can have about you and any information that we might obtain. The most recent version of our Notice of Practices will be with the office receptionist or can be obtained from our office.

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