Thank you for your interest in Telemedicine. Please read our office policies for conducting Telemedicine.
• Integrative Behavioral Health & Healing Practice accepts and bills insurance for Telemedicine visits.
• Benefit investigation is done by the administrative staff for general mental health benefits. It is the patient's responsibility to know coverage for Telemedicine. Self-pay rates will apply should the patient not have Telemedicine/Telehealth coverage.
• Self-pay Telemedicine visits are $175 for a 20min follow up, $200 for a 30 min follow up, $250 for a 40 min follow up, and $400 for a new patient visit.
DURING YOUR SESSION:
• The provider will introduce themself.
• You may be asked to confirm the state you are in and the state where you live. You may also need to show a photo ID.
• Patients under the age of 16 will need to be accompanied by a parent or guardian for the duration of the video session.
• A report of the session will be placed in your medical record. You can get a copy from your provider.
• All laws about the privacy of your health information and medical records apply to Telemedicine. These laws also apply to the video, audio, and photo files that are made and stored.
TELEMEDICINE POLICIES:
• My provider has the discretion to determine whether or not to continue Telemedicine appointments.
• Patients are required to be ready and available at their appointment time. Checking in tardy, missing or canceling less than 24 business hours will result in rescheduling a fee– $175-$250 for follow up visits and $400 for new patient visits.
• The card on file will be charged 24 hours prior to your appointment.
• Your provider uses HIPAA compliant software for Telemedicine.
• Not having Wifi or having a poor connection due to using a data plan is considered missing your appointment.
I certify that I have read, understand, and agree to follow the information provided above regarding telemedicine. I hereby give my informed consent for the use of telemedicine in my medical care.
If the patient is a minor, lacks legal capacity or is unable to sign, an authorized personal representative may sign this form.