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Available Forms

Televisit Consent Form

Prior to the televisit consult, the patient confirmed the following:

You understand that I proposed engaging in a telehealth consult. You understand that a telehealth consultation has potential benefits, including easier access to care and the convenience of meeting from a location of your choosing. You understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. You understand that either you or I could discontinue the telehealth consult if either of us concludes that the video conferencing connections are not adequate for the situation. You understand that its your responsibility to confirm that your insurance carrier will cover the bill. You agree that you will be financially responsible for the bill if the insurance denies coverage.

* Required field