Enlightened Health Telehealth

Enlightened Health Direct - Telehealth Visit

Please complete the form below to begin your telehealth visit. A payment of $39 is required to begin the visit. The doctor’s office will do its best to accommodate your appointment time slot request.
Appointment Slot Preference*

Services*

Telehealth VisitTelehealth visit with a board certified primary care doctor from your phone or computer.

$39.00

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Patient Name*

First NameMiddle NameLast Name
Patient Full Name
Patient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Phone*
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Email*
example@example.com
Marital Status*

SingleMarriedDivorcedWidowed
Marital Status Text
Social Security Number
Sex*

MaleFemale
Date of Birth*

MonthDayYear
Date
Today

MonthDayYear
Date
Age
Emergency Contact Name

First NameLast Name
Emergency Contact Phone
Please enter a valid phone number.
Emergency Contact Relationship
Primary Care Physician Name
Primary Care Physician Phone
Please enter a valid phone number.

	Family Member
Hypertension
Diabetes
Stoke
Cancer
Heart Disease
Thyroid Disease
Osteoporosis
Bleeding Disorder
Glaucoma
Depression/Anxiety
Alcoholism
Migraines

Permission for Telehealth Visits
What is telehealth?

Telemedicine, also referred to as telehealth medicine, is the real-time, audio-visual visit between a provider and patient. It can be used asan alternative to traditional in-person care delivery and, in certain circumstances, can be used to deliver care including the diagnosis,consultation, treatment, education, care management and patient self-management.

How do I use telehealth?

You talk to your provider with a phone, computer or tablet. Sometimes, you use video so you and your provider can see each other.

How does telehealth help me?

You don’t have to go to a clinic or hospital to see your provider. It also reduces your risk of getting sick from other people.

What are some of the benefits of telehealth?

No transportation time or costs, reduced wait time, and more detailed and personalized care compared to a telephone call.

What are some of the challenges of telehealth visits?

You and your provider won’t be in the same room, so it may feel different from an office visit. Your provider cannot examine you as closelyas they might at an in-office visit. Your provider may decide you still need an office visit. Technical problems may interrupt or stop yourvisit before you are done.

Will my telehealth visit be private?

We will not record visits with your provider. If people are close to you, they may hear something you do not want them to know. You shouldbe in a private place so other people cannot hear you. Your provider will tell you if someone else from their office can hear or see you. We use HIPAA-compliant, encrypted telehealth technology that is designed to protect your privacy. If you use the internet for telehealth, use anetwork that is private and secure. There is a very small chance that someone could use technology to hear or see your telehealth visit.

What types of visits can telehealth be used for?

Telehealth is best suited for interactions with established patients who do not require a physical exam or lab work.

What types of visits are not appropriate for telehealth?

Telehealth is not suited for a physical examination or lab testing, and cannot be used for new-patient evaluations.

What if I want an office visit, not a telehealth visit?That decision is up to you and your provider. Find out what options are available to you by calling the practice.

What if I try telehealth and don’t like it?

You can stop using telehealth any time, even during a telehealth visit. You can still get an office visit if you no longer want a telehealthvisit. If you decide you do not want to use telehealth again, call 817-583-5910 and say you want to stop.

How much does a telehealth visit cost?

No costs for telehealth visit under direct primary care membership. If your provider decides you need an office visit in addition to yourtelehealth visit, there is no additional costs as part of your direct primary care membership.

Do I have to sign this document?

No. Only sign this document if you want to use telehealth.

What does it mean if I sign this document?

If you sign this document, you agree that: We talked about the information in this document. We answered all your questions. You want a telehealth visit.
Your name*
Date*

MonthDayYear
Date
Signature*

Clear
Should be Empty:

	Name	Dose	How Often
Medication 1
Medication 2
Medication 3
Medication 4

	Operation	Date
Surgery 1
Surgery 2
Surgery 3
Surgery 4

Enlightened Health Direct - Telehealth Visit

Health History

Habits

Family History

Acknowledgment of Receipt of Notice of Privacy Practices

Permission for Telehealth Visits