Telehealth Consent

Telehealth (also called telemedicine) is a way to visit your healthcare physician without going to a hospital or clinic. The visits are held by computer, tablet, or telephone.
This form gives permission for telehealth communication between Preferred Foot and Ankle and you, the patient.

• I understand telehealth is NOT an emergency service and in the event of an emergency, I will use a phone to call 911.
• I understand that telehealth involves sharing my health information electronically. I will tell my healthcare physician if there is any additional information that I do not want to talk about in a telehealth visit.
• I understand that I may stop the telehealth visit at any time. If I decide to stop, I will still be able to receive care at this office.
• I understand that telehealth visits carry some level of risk, including but not limited to:
  • My computer, tablet, or phone may not be private and secure, especially if other people use it. It is my responsibility to make sure my internet system is private and secure and to make sure I am in a private place during the visit.
  • Technical problems may interrupt or stop the visit before it is done. 
  • My healthcare physician cannot examine me as closely during a telehealth visit, and this may make it harder to determine what is wrong with me. 
• I agree that information shared during my telehealth visit will be kept by the healthcare physician and facilities involved in my care. 
• I understand that I will be asked to confirm my identity and current location to the healthcare physician seeing me.
• I also have the right to confirm the identity and credentials of the healthcare physician who will be seeing me. 
• I agree to follow my healthcare physician’s recommendations, including lab tests and x-rays, sending me to a specialist, or asking me to come to the office or go to an emergency department for an in-person visit.

I certify that I fully understand the benefits and limitations of telehealth and agree to proceed with the telehealth visit.

Printed Name of Patient or authorized representative:
First Name   Last Name   
Patient Signature:
Signature   
Today’s Date:
Date   

Custom Orthotic/AFO Agreement

After this visit, I give Preferred Foot and Ankle permission to submit a claim to my insurance company. I will be notified when the insurance has responded to the claim. I will have the option to move forward if the custom-molded orthotics and/or AFO are covered or not by my insurance company.

I am aware that the custom-molded products are $400 self-pay in the office.

Delivery Notice: When the devices arrive in the office, you will be contacted to schedule an appointment for fitting and dispense. Upon dispense, the devices must be paid in full by either your insurance or self-pay. Because they are custom-made, they are not refundable.

I agree that if 3 attempts have been made to notify me in multiple ways, and there is no response on my behalf, the devices will be discarded after one year.

By signing below, I acknowledge that I have read this agreement, and everything has been fully explained to me.

Patient Signature:
Signature   
Today's Date
Date