Patient Financial Responsibility Consent
Telehealth involves the use of secure electronic communications, information technology, or other means to enable a healthcare provider at one location, and a patient in another location to share individual patient clinical information for the purpose of consulting with, diagnosing, treating, prescribing, and/or referring the patient to in-person care, as determined clinically appropriate. Telehealth services offered by Form Health Associates (MA), P.C. and the members of its Affiliated Covered Entity (collectively “Form Health Associates,”), Healthy Life Physicians Group Pacific Northwest, P.C., and Form Associates, P.A. (collectively, “Form Health”) may include a patient consultation, diagnosis, treatment recommendation, prescription, and/or a referral to in-person care, as determined clinically appropriate.
By checking the box associated with "PATIENT RESPONSIBILITY CONSENT FORM", you acknowledge that you understand and agree with the following:
- As part of my current treatment plan with my Form Health physician, my physician will be providing a diagnosis, treatment recommendation, and/or prescription through the use of certain electronic communications, software and devices.
- I understand that these telehealth services are separate services for which Form Health will bill my insurance payers, including Medicare or Medicaid.
- I understand that my payer may not cover all of the billed amount. I understand I am responsible for paying Form Health for any and all of such amounts not paid by my insurance payer, including non-covered charges and all copayments, coinsurance, and deductibles. I understand that Form Health will charge my credit card for any amounts not covered by my payer following a visit with my Form Health physician, and that I may not receive a bill from Form Health.
- I understand that if I do not provide Form Health with at least two (2) business day notice of cancellation and do not attend a scheduled visit, I may be charged a fee of up to one hundred dollars ($100.00) that will be charged directly against my credit card.
By checking the Box for this "PATIENT RESPONSIBILITY CONSENT FORM" I hereby state that I have read, understood, and agree to the terms of this document.