Telehealth Consent & Financial Responsibility
I voluntarily consent to receive healthcare services through secure telehealth technology (audio and/or video).
I understand and agree that:
* Telehealth visits will be billed to my insurance when applicable.
* Insurance coverage and payment for telehealth services vary by plan and are not guaranteed.
* I am responsible for any copays, deductibles, coinsurance, non-covered services, or denied claims.
* If my insurance does not pay for the telehealth visit, I agree to be responsible for the remaining balance.
* If I do not have insurance or choose not to bill insurance, I agree to pay according to the practice’s current fee schedule.
* Payment may be collected before or at the time of service when required.
Medicare ABN Acknowledgment (For Medicare Patients Only)
I understand Medicare coverage is based on medical necessity, coverage rules, and Medicare requirements. Telehealth services are not automatically covered. If Medicare requires an Advance Beneficiary Notice of Noncoverage (CMS-R-131), I understand I will receive and sign the official ABN before the service is provided. I understand Medicare or my insurance may deny payment, and I may be responsible for charges not covered.
Estimated Telehealth Visit Fees
| Office Visit |
Standard Fee |
Cash Pay / Prompt Pay / Insurance Denied Discount |
| 99213 + G2211 |
$399.00 |
$199.50 |
| 99214 + G2211 |
$521.00 |
$260.50 |
| 99215 + G2211 |
$690.00 |
$345.00 |
Fees listed above include the telehealth visit only. Additional services such as labs, imaging, procedures, injections, medications, or medical equipment are billed separately. Payment plans may be available if needed.
Insurance Coverage Information
Many insurance plans cover medically necessary telehealth visits when the patient is at home and the provider is located at the clinic. Numerous insurance plans cover telehealth visits the same way they cover in-person office visits, meaning patients are responsible for any applicable copays, deductibles, or coinsurance according to their individual benefits. Many insurance companies use Medicare telehealth guidelines when creating their coverage policies; however, each insurance plan has its own rules, requirements, and benefits. Because coverage varies by insurance plan, payment for telehealth services cannot be guaranteed. Telehealth claims may be denied due to reasons including:
* Non-covered or excluded services
* Benefit or frequency limits
* Medical necessity or diagnosis requirements not met
* Prior authorization or other insurance requirements not completed
* Services considered non-covered by the insurance plan
* Medicare telehealth flexibilities are currently extended through December 31, 2027, subject to federal law and Medicare regulations.
Assignment of Benefits & Billing Agreement
I authorize payment of insurance benefits directly to my provider and authorize the release of medical information necessary to process claims. I understand that I am responsible for all balances not paid by my insurance, except amounts the practice is required to adjust by contract. This includes deductibles, copays, coinsurance, denied claims, and non-covered services. Unpaid balances are subject to the practice’s billing and collection policies, which may include referral to a collection agency and applicable collection fees as permitted by law.
Patient Authorization
X I elect to receive the telehealth services described above. I authorize my provider to bill my insurance. If my insurance denies payment or pays less than the amount billed, I agree to be financially responsible for the remaining balance. This consent applies to today's telehealth visit and future telehealth services provided by this practice unless revoked or changed in writing.
Patient Acknowledgment
By signing below, I acknowledge that:
* I have read and understand this Telehealth Financial Consent and Financial Responsibility Agreement.
* I understand insurance coverage and payment are not guaranteed.
* I understand I may be responsible for charges not covered by my insurance.
* I have had the opportunity to ask questions.
My electronic signature is valid and has the same effect as a handwritten signature to the extent permitted by law.
For questions regarding telehealth coverage, please contact the insurance company using the phone number on the back of your insurance card.