Telemedicine Patient Intake Form

Abramov Services in Adult Health NP P.C. provides medical services via a telehealth platform. Telehealth involves the use of electric communications to enable providers at different locations to share individual client information for the purpose of improving client care. The information may be used for diagnosis, therapy, follow-up and/or education and may include client health records, live two way audio and video and output data from health devices and sound and video files. If you elect to receive our telehealth services, you must give informed consent and agree to the following: Nature of Telehealth Consult: Our telehealth sessions are provided through Tebra, a HIPAA compliant and secure platform. By using this service, you agree to their terms of use and privacy policy. Medical Information & Records: All existing laws regarding your access to medical information and copies of your medical records apply to this telehealth consultation. No recording of the session will be done unless verbal consent is given. Additionally, dissemination of any patient identifiable images or information for this telehealth interaction to any other parties or entities shall not occur without your consent. Risks, Consequences & Benefits: There are potential risks with the use of telehealth technology, including but not limited to: (1) interruption of the audio/video link, (2) disconnection of the audio/video link, (3) video that may not be clear enough to meet the needs of the consultation, and (4) potential of unauthorized access to the live or stored consultation. If any of these occur, the consultation may need to be stopped and/or rescheduled. Also, we are not responsible for these or other technology problems that we are not in control of. We strive to provide telehealth services at the same standard of care of an in-person visit. However, there may be some limitations to what we can do through a telehealth session compared to a face-to-face visit. If the limitations of a telehealth session will interfere with our ability to properly examine or treat you, we will let you know so you can schedule a face-to-face visit with us or another provider of your choice. If you do not feel safe, you must tell us. If the exercise or activity requires the assistance of a family member or caregiver (collectively “Caregivers”), you are accepting the risk of the actions of your Caregivers. We are not responsible if you fall or get injured by the actions, errors or omissions of your Caregiver. Privacy and Confidentiality: Reasonable and appropriate efforts have been made to eliminate any confidential risks associated with telehealth sessions, and all existing confidentiality protections under state and federal law apply to information disclosed during this telehealth consultation. The same state and federal laws that protect your privacy and the confidentiality of your medical records apply to our telehealth visits if the visit is for health care services. You acknowledge by signing below that you have been given an opportunity to review our Notice of Privacy Practices and had all your questions answered. You understand that no physical exam will be given during a telehealth visit and agree to the providers plan of care that may be modified for telehealth. Billing & Financial Responsibility: Some health plans may cover telehealth services, if the health plan would have covered the same interventions had they been provided in the office. However, there are frequent exceptions to these coverage laws and policies. That means your health plan may deny our claims for telehealth services. Therefore, by consenting to receive our services through a telehealth means, you agree to personally pay for any services your health plan does not cover, even if your Explanation of Benefits (EOB) from your health plan states you owe $0 for our services. You understand that you are responsible for any copayments or coinsurance that apply to your telehealth visits. If telehealth service is not covered by your health plan, you have the option of paying for this service at the rate of $150 for consultation. You may withhold or withdraw your consent to the telehealth consultation at any time without affecting your right to future care or treatment. I, ______________________________________ [print name], have read, understand and agree to all the above terms for my telehealth session. Understanding the limitations and risks associated with a telehealth consultation as described above, I consent to the examination and/or treatment through Abramov Services in Adult Health, NP P.C. telehealth services. This form is in addition to the Consent for Treatment & Office Policies forms I signed at the time of my initial evaluation.