Telehealth Annual In-Person Visit Exception Form

  • Telehealth Annual In-Person Visit Exception Form

    For Client Use
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  • Reason for Exception to 12-Month In-Person Visit Requirement

  • In accordance with CMS guidelines, an exception to the requirement for an in-person, non-telehealth service within 12 months of a telehealth mental health service may be made when the risks and burdens of an in-person visit outweigh the benefits.

    • Patient and provider agree that risks/burdens outweigh benefits.
    • Basis for decision documented below:

  • The in-person session requirement is likely to disrupt my therapy services due to challenges with being able to attend a session in-person

  • The in-person session requirement has the potential to worsen my health conditions

  • I am in therapy for a maintenance level of care and I am not in a crisis that requires an in-person session

  • The in-person session requirement would cause undue hardship on myself or my family

  • The in-person session requirement presents a risk of not being able to continue with this effective treatment due to my inability to come to the office

  • Other

  • I acknowledge that Heart and Solutions is relying on the accuracy of the information provided. Failure to provide truthful or adequate information may result in services not being covered by Medicare. I understand that if any of the statements or information I provide in this document are false, incomplete, or deemed insufficient by Medicare, and Medicare subsequently denies or revokes payment for therapy claims, I will be held financially responsible for any claims for which Medicare denies or recoups payment.

    I understand that I have the ability to obtain any needed point of care services by calling 911 or going to my local hospital in an emergency, or scheduling an in-person appointment at any of our Heart and Solutions office locations should I need in-person care in the future.

  • Clear
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  • Should be Empty: