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., a Massachusetts professional corporation or Form Health Associates, P.C., a California medical corporation (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:

  1. 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. 
  2. I understand that these telehealth services are separate services for which Form Health will bill my insurance payers, including Medicare or Medicaid.  
  3. 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.  
  4. 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 twenty dollars ($20.00) that will be charged directly against my credit card. 

□ ACCEPT. 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.