Fee Schedule - IIH Telemedicine

IIH (Idiopathic Intracranial Hypertension) Evaluation

1)  Evaluation, plan, and education: $1,550 Cashier's Check / Cash / Credit Card / Flex Spending Account 

2) Cost of Follow-Up Care: $275/ 30-minute calls. You can have as many or as few of these visits as you prefer. Most patients enjoy 2-4 follow-up calls.

Payments: 

• $300 collected at the time we accept your case. We begin working on your case immediately
• The remaining balance of $1,250 is due the day before your appointment. 

Rescheduling or Canceling:

• We will allow you to cancel or reschedule your appointment at no additional cost if you do so at least 3 weeks before your appointment date. We do not allow appointments to be rescheduled more than once.
• If you must reschedule or cancel your appointment within 3 weeks of your scheduled date, you will forfeit your deposits (collected for work done so far on your case).

Additional Fees: $150 for each requested letter/form regarding disability, parking, school, work, travel, jury duty, FMLA, SSI, ADA, ect. that we complete for you. 

     Because IIH is often complicated by numerous overlapping disorders, it is important to understand what is included in your fee (the evaluation and treatment of IIH), and what your medical team should address (overlapping disorders, including inflammatory disorders driving the change in intracranial pressure). Overlapping disorders and presentations such as POTS, Chronic Fatigue Syndrome, joint pain and others are outside the scope of our IIH evaluation and treatment. Instead, we will focus on identifying IIH if it exists, treating it, and teaching you how to maximize treatment and minimize complications of medications. If you have POTS, please understand that we will not be treating POTS.

What is included in your evaluation:

Brain and cervical MRI: Detailed review of your brain/cervical MRI (your recent MRI or will may order one that you can have completed locally). We will send instructions on how to get us your previous MRI if you have had one.

Blood Work

We will provide you with a blood work order. The above fees do not include the cost of blood work (it is the responsibility of the lab to send this to insurance if applicable). We will not bill you for any additional fees associated with costs of the blood draw. Please keep in mind that there are some tests that may not be covered with some insurance companies. In this case, you will be responsible for these fees.
International Patients: International patients will need to pay for the blood work directly to the laboratory or physician drawing their blood. 

Medications 

The prescriptions we provide you will be good for up to a year.

Education

We will teach you about your condition, how to manage it, and how to minimize complications with medications, and how to maximize your success.

Your Initial Evaluation and Visit

After we have received this form, your brain MRI results, and blood work results, we will then meet with you over a Google Meet. Please plan on approximately 3 hours for this visit. We will speak with you over a phone call a day after beginning medication (if you need medication) and we will schedule another Google Meet with you to cover your treatment summary and be sure your questions are answered.

Follow-up care 

Follow-up care costs $275/ 30-minute call. You can schedule as many or as few as you want for one year. On average, most patients schedule a couple of these.

Insurance

POTS Care does not take insurance of any kind and will not appeal to insurance for reimbursement (i.e. with letters, phone calls, diagnosis codes, procedure codes, etc). All services, tests, procedures, evaluations rendered at POTS Care will be subject to private pay only. Bloodwork, prescriptions, etc. will be the financial responsibility of the patient and facility/institution that is rendering said services. 

 

IF YOU HAVE MEDICARE, YOU MUST SIGN BELOW.  If you do not have Medicare, please skip this step. 

ATTENTION MEDICARE/MEDICAID PATIENTS

IF YOU HAVE MEDICARE, YOU MUST SIGN THIS FORM. If you do not have Medicare, please skip this step. 

This agreement is between the Doctors of POTS Care PLLC, and the patient and is a Medicare Part B beneficiary seeking services covered under Medicare Part B pursuant to Section 4507 of the Balanced Budget Act of 1997. The Doctors have informed Patient that Doctors of POTS Care have opted out of the Medicare program, originally effective on October 1, 2022. Doctors opt out every two years. 

Doctors agree to provide medical services to Patient. 

In exchange for the Services, the Patient agrees to make payments to POTS Care PLLC pursuant to the Fee Schedule. Patient also agrees, understands and expressly acknowledges the following: 

• Patient agrees not to submit a claim (or request that Doctors submit a claim) to the Medicare program with respect to the Services, even if covered by Medicare Part B.
• Patient is not currently in an emergency or urgent health care situation.
• Patient acknowledges that neither Medicare’s fee limitations nor any other Medicare reimbursement regulations apply to charges for the Services. 
• Patient acknowledges that Medi-Gap plans will not provide payment or reimbursement for the Services because payment is not made under the Medicare program, and other supplemental insurance plans may likewise deny reimbursement. 
• Patient acknowledges that he/she has a right, as a Medicare beneficiary, to obtain Medicare-covered items and services from physicians and practitioners who have not opted-out of Medicare, and that the patient is not compelled to enter into private contracts that apply to other Medicare-covered services furnished by other physicians or practitioners that have opted-out. 
• Patient agrees to be responsible, whether through insurance or otherwise, to make payment in full for the Services, and acknowledges that the Doctors will not submit a Medicare claim for the Services and that no Medicare reimbursement will be provided. 
• Patient understands that Medicare payment will not be made for any items or services furnished by the physicians that would have otherwise been covered by Medicare if there were no private contract and a proper Medicare claim were submitted. 
• Patient acknowledges that a copy of this contract has been made available to him/her. 

General Consent for Care and Treatment

POTS Care, PLLC is compliant with Texas Business Organizations Code § 301.012, Joint Practice by Certain Professionals, which allows for persons licensed as doctors of medicine by the Texas State Board of Medical Examiners and persons licensed as optometrists or therapeutic optometrists by the Texas Optometry Board to, subject to the provisions regulating those professionals, jointly form and own a professional limited liability company to perform professional services that fall within the scope of practice of those practitioners. The providers at POTS Care, PLLC work collaboratively, within their respective licenses, to treat patients suffering from POTS. 

I understand that POTS Care is a group practice including Dr. Derek Lang, DO as Medical Director, Dr. Diana Driscoll, OD,FAAO as Clinical Director, and additional physicians as needed. Dr. Diana Driscoll, OD, FAAO, will be a significant point of communication with you, but the entire medical team works together to determine the best treatment approach in your case, including medications, supplements, and lifestyle changes if needed. 

You have the right, as a patient, to be informed about your condition and the recommended surgical, medical or diagnostic procedure to be used so that you may make the decision whether or not to undergo any suggested treatment or procedure after knowing the risks and hazards involved. At this point in your care, no specific treatment plan has been recommended. This consent form is simply an effort to obtain your permission to perform the evaluation necessary to identify the appropriate treatment and/or procedure for any identified condition(s).

This consent provides us with your permission to perform reasonable and necessary medical examinations, testing and treatment. By signing below, you are indicating that (1) you intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended; and (2) you consent to treatment at this office or any other satellite office under common ownership. The consent will remain fully effective until it is revoked in writing. You have the right at any time to discontinue services. You have the right to discuss the treatment plan with your physician about the purpose, potential risks, and benefits of any test ordered for you. If you have any concerns regarding any test or treatment recommended by your healthcare provider, we encourage you to ask questions.

I voluntarily request a physician, and/or mid-level provider (Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist), and other health care providers or the designees as deemed necessary, to perform reasonable and necessary medical examination, testing and treatment for the condition which has brought me to seek care at this practice. I understand that if additional testing, invasive or interventional procedures are recommended, I will be asked to read and sign additional consent forms prior to the test(s) or procedure(s). 

I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents. 

This form clarifies some aspects of telemedicine. Please let us know if you have any questions. 

INFORMED CONSENT TO TELEMEDICINE CONSULTATION

1. The purpose is to assess and treat my medical condition.
2. The telemedicine consultation is done through a two-way video link-up whereby the physician or other health provider at POTS Care, PLLC can see my image on the screen and hear my voice.  However, unlike a traditional medical consult, the physician or other health provider does not have the use of the other senses such as touch or smell, and it may not be equal to a face-to-face visit.
3. Since the telemedicine consultants practice in a different location and do not have the opportunity to meet with me face-to-face, they must rely on information provided by me or my onsite healthcare providers.  POTS Care, PLLC and affiliated telemedicine consultants can not be responsible for advice, recommendations and/or decisions based on incomplete or inaccurate information provided by me or others.
4. I can ask questions and seek clarification of the procedures and telemedicine technology.
5. I can ask that the telemedicine exam and/or videoconference be stopped at any time.
6. I know there are potential risks with the use of this technology. These include but are not limited to:
    a. Interruption of the audio/video link
    b. Disconnection of the audio/video link
    c. A picture that is not clear enough to meet the needs of the consultation
    d. Electronic tampering

If any of these risks occur, the procedure may need to be stopped.

7. I understand I can make a complaint of my provider to the Texas Medical Board by going online at http://www.tmb.state.tx.us/page/place-a-complaint or calling the Complaint Hotline at 800-201-9353.
8. In order to participate in the telemedicine program, I agree to be charged the remaining balance on the first day of the telemedicine visit. By signing this consent, I agree to the charges on my credit card. 

I, the undersigned patient, do hereby understand and state that I agree to the above consents.  I certify that this form has been fully explained to me.  I have read it or have had it read to me.  I understand and agree to its contents.  I volunteer to participate in the telemedicine examination.  I authorize POTS Care, PLLC and the doctors, nurses and other providers involved to perform procedures that may be necessary for my current medical condition.

Notice of Privacy Practices

Effective April 1, 2015

This Notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. If you have any questions, please contact our office. We are required by law to maintain the privacy of your protected health information, give you this notice of our duties and privacy practices regarding health information about you, and follow the terms of our notice that is currently in effect.

HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION:

Described as follows are the ways we may use and disclose health information that identifies you (Health Information, or PHI). Except for the following purposes, we will use and disclose Health Information only with your written permission. You may revoke such permission at any time by writing to us and stating that you wish to revoke permission you previously gave us.

Treatment. We may use and disclose Health Information for your treatment and to provide you with treatment-related health care services. For example, we may disclose Health Information to doctors, nurses, technicians, or other personnel, including people outside our office, who are involved in your medical care and need the information to provide you with medical care.  
Payment. We may use and disclose Health Information so that we may bill and receive payment from you or a third party for the treatment and services you received. For example, we may give your health plan information so that they will pay for your treatment. However, if you pay for your services yourself (e.g. out-of-pocket and without any third-party contribution or billing), we will not disclose Health Information to a health plan. 
Health Care Operations. We may use and disclose Health Information for health care operation purposes. These uses and disclosures are necessary to make sure that all of our patients receive quality care and to operate and manage our office. For example, we may use and disclose information to make sure the care you receive is of the highest quality.

Records Release to You. We will provide a copy or a summary of your Health Information in response to a request for a copy of your records made by you or medical personnel whom you have so designated to receive information involved in your care in the format requested.

I am requesting:

   X   Summary of Health Information

OR

   __  Copy of Records

Appointment Reminders, Treatment Alternatives and Health Related Benefits and Services. We may use and disclose Health Information to contact you and to remind you that you have an appointment with us. We also may use and disclose Health Information to tell you about treatment alternatives or health-related benefits and services that may be of interest to you.
Release of Health Information to Family, Friends and Associates. We will only share Health Information with non-medical personnel (such as your family, friends, and associates) you have specifically designated in “Permission to Release PHI”, attached. We also may notify your family about your location or general condition or disclose such information to an entity assisting in a disaster relief effort.

Research. Under certain circumstances, we may use and disclose Health Information for research. For example, a research project may involve comparing the health of patients who received one treatment to 

those who received another, for the same condition. If a retrospective chart analysis is performed, your 

records will be “de-identified” so that no one outside of POTS Care, PLLC has any means to identify you.
Fundraising and Marketing. Health Information may be used for fundraising communications. Except for the exceptions detailed above, uses and disclosures of Health Information for marketing purposes, as well as disclosures that constitute a sale of Health Information, require your written authorization

Other Uses. We may be allowed or required to share your information in other ways that contribute to the public good. We have to meet many conditions in the law before we can share your information for these purposes. Such reasons may include help with public health and safety issues, compliance with the law, response to organ and tissue donation requests, working with a medical examiner or funeral director, answering workers’ compensation, law enforcement, and other government requests, and responding to lawsuits and legal actions. For more information see: www.hhs.gov/ocr/privacy/hipaaunderstanding/consumers/index.html.

SPECIAL SITUATIONS:
As Required by Law. We will disclose Health Information when required to do so by federal, state or local law.
To Avert a Serious Threat to Health or Safety. We may use and disclose Health Information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Disclosures, however, will be made only to someone who may help prevent the threat. 
Business Associates. We may disclose Health Information to our business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. For example, we may use another company to perform billing services on our behalf. All of our business associates are obligated to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.
Organ and Tissue Donation. If you are an organ donor, we may use or release Health Information to organizations that handle organ procurement or other entities engaged in procurement; banking or transportation of organs, eyes, or tissues to facilitate organ, eye or tissue donation; and transplantation.
Military and Veterans. If you are a member of the armed forces, we may release Health Information as required by military command authorities. We also may release Health Information to the appropriate foreign military authority if you are a member of a foreign military.
Workers' Compensation. We may release Health Information for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness.
Public Health Risks. We may disclose Health Information for public health activities. These activities generally include disclosures to prevent or control disease, injury or disability; report births and deaths; report child abuse or neglect; report reactions to medications or problems with products; notify people of recalls of products they may be using; a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.
Health Oversight Activities. We may disclose Health Information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.  
Lawsuits. If you are involved in a lawsuit or a dispute, we may disclose Health Information in response to a court or administrative order. We also may disclose Health Information in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested. 
Law Enforcement. We may release Health Information if asked by a law enforcement official if the information is: (1) in response to a court order, subpoena, warrant, summons or similar process; (2) limited information to identify or locate a suspect, fugitive, material witness, or missing person; (3) about the victim of a crime even if, under limited circumstances, we are unable to obtain the person's agreement; (4) about a death we believe may be the result of criminal conduct; (5) about criminal conduct on our premises; and (6) in an emergency to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime.
Coroners, Medical Examiners and Funeral Directors. We may release Health Information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We also may release Health Information to funeral directors as necessary for their duties.
National Security and Intelligence Activities. We may release Health Information to authorized federal officials for intelligence, counter-intelligence, and other national security activities authorized by law. 
Protective Services for the President and Others. We may disclose Health Information to authorized federal officials so they may provide protection to the President, other authorized persons, or foreign heads of state, or to conduct special investigations.
Inmates or Individuals in Custody. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release Health Information to the correctional institution or law enforcement official. This release would be if necessary: (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) the safety and security of the correctional institution.

 

YOUR RIGHTS: 

You have the following rights regarding Health Information we have about you: 

Right to Inspect and Copy. You have a right to inspect and obtain Health Information that may be used to make decisions about your care or payment for your care. This includes medical and billing records, other than psychotherapy notes. To inspect and obtain a copy of this Health Information, you must make your request, in writing, to our office. 

Right to Amend. If you feel that Health Information we have is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for our office. To request an amendment, you must make your request, in writing, to our office.
Right to an Accounting of Disclosures. You have the right to request a list of certain disclosures we made of Health Information for purposes other than treatment, payment and health care operations or for which you provided written authorization. To request an accounting of disclosures, you must make your request, in writing, to our office.
Right to Request Confidential Communication. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. Such requests must be made in writing by providing us with a completed “Communication Request” form, attached. We will accommodate reasonable requests.
Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You may obtain a copy of this notice at our web site, www.POTSCare.com. To obtain a paper copy of this notice please request it in writing. 
Right to Electronic Records. You have the right to receive a copy of your electronic health records in electronic form. 
Right to Breach Notification. You have the right to be notified if there is a Breach of privacy such that your Health Information is disclosed or used improperly or in an unsecured way.

 

CHANGES TO THIS NOTICE: 

We reserve the right to change this notice and make the new notice apply to Health Information we already have as well as any information we receive in the future. We will post a copy of our current notice at our office.

 

COMPLAINTS: 

If you believe your privacy rights have been violated, you may file a complaint with our office or with the U.S. Department of Health and Human Services Office for Civil RIghts by sending a letter to 200 Independence Avenue, S.W., Washington, D.C.20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. All complaints must be made in writing. You will not be penalized for filing a complaint.

Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, acupuncturists, and surgical assistants may be reported for investigation at the following address: 

Texas Medical Board Attention: Investigations 

333 Guadalupe, Tower 3

Suite 610 P.O. Box 2018

MC-263 Austin, Texas 78768-2018 

Assistance in filing a complaint is available by calling the following telephone number: 1-800-201-9353 

For more information please visit our website: www.tmb.state.tx.us

I acknowledge having been provided this Notice of Privacy Practices.

Media Release Form

I hereby authorize POTS Care, hereby referred to as “Company,” to publish photographs taken of me and my name and likeness, for use in the Company’s print, online, and video-based marketing materials, as well as other Company publications.

I hereby release and hold harmless Company from any reasonable expectation of privacy or confidentiality associated with the images specified above.

I further acknowledge that my participation is voluntary and that I will not receive financial compensation of any type associated with the taking or publication of these photographs or participation in company marketing materials or other Company publications. I acknowledge and agree that publication of said photos confers no rights of ownership or royalties whatsoever.

I hereby release Company, its contractors, its employees, and any third parties involved in the creation or publication of marketing materials, from liability for any claims by me or any third party in connection with my participation.

 

Media release authorization: 

Permission to Release PHI

I allow release of requested PHI (“Protected Health Information”) to the following friends, family and associates:

Communication Request

At POTS Care, PLLC, we will be communicating with you via email concerning your care, appointments, and billing. 

Please list below all emails you would like added to your patient communications: