Corstrata Virtual Ostomy Support Services - Scheduling & Payment Information

Welcome to Virtual Ostomy Support Services

Bienvenido a los servicios de apoyo virtual para ostomías
At this time, Services may only be received in the following States/En este momento, los Servicios solo se pueden recibir en los siguientes Estados:

AR, AZ, CA, CO, FL, GA, ID, IL, KY, LA, MA, MO, MS, NC, NJ, NM, NV, NY,

OH, OR, PA, RI, SC, TN, TX, VA, WA, WI

*More states coming soon*/*Pronto habrá más estados*

Pricing - $80 for 45 minutes/Precio: $80 por 45 minutos

*Corstrata services are private pay, out-of-pocket expenses, and are eligible for reimbursement with a FSA, HSA, and HRA./*Los servicios de Corstrata son pagos privados, gastos de bolsillo y son elegibles para reembolso con una FSA, HSA y HRA.
Please select the patient's primary language/Por favor seleccione el idioma principal del paciente:*

EnglishEspañol
Is the patient?*

an adult (18+)a child (17 and under)/or has legal guardian
CLICK HERE to learn how to make the most of your visit
Please select a date and time for an Adult (18 years of age and older):
Please select a date and time for a child (17 years or younger) or if the patient has a legal guardian.
Seleccione la 1.ª opción para un niño o tutor legal y la 2.ª opción para un adulto:
HAGA CLIC AQUÍ para saber cómo aprovechar al máximo su visita
Consult Charge/Consultar cargo*
prevnext( X )
Ostomy Visit/Visita de ostomia45 minutes with a Certified Ostomy Nurse. Note - additional charges may apply if visit goes over allotted time. $25 per additional 15 minutes/45 minutos con una enfermera ostomista certificada. Nota: pueden aplicarse cargos adicionales si la visita excede el tiempo asignado. $25 por cada 15 minutos adicionales
$80.00

Total

$0.00
Your Name*

First NameLast Name
I am requesting services for*

SelfMinorAnother Adult
If for minor or another adult, please provide their name

First NameLast Name
Patient's Home Address/Location of services rendered*

Street Address

Street Address Line 2

CityState

Zip Code
Email Address*
Phone Number*
Preferred Method of Contact*

EmailPhone Call
Medical Emergency Contact Information

For Emergency Purposes
In the event of a medical emergency during my virtual ostomy visit, I, the patient and/or the authorized signer for the patient,*

give consent for Corstrata to call my medical emergency contact and release my Protected Health Information to ensure proper medical care is provided.do NOT give consent for Corstrata to contact the Medical Emergency Contact listed below.
Emergency Contact Name

First NameLast Name
Phone Number
Relationship to Patient
Date of Birth*

MonthDayYear
Date
Sex*

FemaleMale
How much time has it been since your surgery?*

Less than 3 months3 to 12 monthsMore than 1 year
What type of ostomy do you have (Check all that apply)?*

ColostomyIleostomyUrostomyNot sure
What is the reason for scheduling a visit with our virtual support services (Check all that apply)?*

How to care for my ostomyIssues regarding my stoma or surrounding skinConcerns about my appliance - leakage, frequent changes, etc.Other
How did you hear about Corstrata's ostomy support services?*

Social media - i.e.Twitter, Instagram, Facebook, LinkedInFriend or family memberReferring providerProduct manufacturer or supplierOther
Referring Provider Information & Authorization Release
List your Referring Provider's Name

First NameLast Name
Office Phone #
Email
Authorization for Release of Protected Health Information

I, the patient and/or the authorized signer for the patient, acknowledge and hereby authorize the release of my Protected Health Information, found on the Corstrata Visit Summary and/or Manufacturer Sampling Form, to the above listed referring provider. I may revoke this authorization at any time in writing to Corstrata, Inc. at P.O. Box 30643, Savannah, GA 31410 or via email at Support@Corstrata.com. If I do revoke this authorization, it will not have effect on any actions taken prior to receiving the revocation. Unless otherwise revoked, this authorization will expire in 90 days from the date of signature below.
By signing your signature below, you are confirming that you have read and understand the above authorization and/or consent, and agree to the terms and conditions of Corstrata's Virtual Ostomy Support Services.*

Clear
If authorized signer, please list full name and relationship to patient:
Date*

MonthDayYear
Date
Should be Empty:

Welcome to Virtual Ostomy Support Services

Medical Emergency Contact Information

Referring Provider Information & Authorization Release