Anxiety and Depression Telemedicine Visit

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TERMS OF SERVICE
I am NOT covered by Medicare or MedicaidI am covered by Medicare or Medicaid and I agree to the terms of the Advanced Beneficiary Notice (ABN) below
Advanced Beneficiary Notice

Patient is solely responsible for paying out-of-pocket the full charge for this visit. This service is not covered under Medicare or Medicaid. Omnia TeleHEALTH will not submit a bill to or request for payment from Medicare and Medicaid or any other payor.

You should NOT use Omnia TeleHEALTH if you are experiencing an emergency. Emergencies include but are not limited to:
- Severe or unusual chest pain
- Severe shortness of breath
- Symptoms of a stroke (such as facial drooping, arm weakness, or speech difficulties)
- Thoughts of harming yourself or others
Yes, I am having an emergencyNo, I am NOT having an emergency

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Telemedicine Visit

$39.00

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Rows	Not at all (0)	Several Days (1)	More Than Half The Days (2)	Nearly Every Day (3)
Feeling nervous, anxious, or on edge
Not being able to stop or control worrying
Worrying too much about different things
Trouble relaxing
Being so restless that it's hard to sit still
Becoming easily annoyed or irritable
Feeling afraid as if something awful might happen

Rows	Not at all (0)	Several Days (1)	More Than Half The Days (2)	Nearly Every Day (3)
Litlle interest or pleasure in doing things
Feeling down, depressed, or hopeless
Trouble falling or staying asleep, or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about self - feelings of failure or having let family or self down
Trouble concentrating on things, such as reading the newspaper or watching television
Moving or speaking so slowly that other people could have noticed. Or, the opposite - being fidgety or restless, moving around a lot more than usual
Thoughts of hurting self in some way or thoughts of being better off dead

TERMS OF SERVICE