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*** Telemedicine Consent and Patient Agreement

Telemedicine Consent and Patient Agreement

Only parent or legal guardian may sign this form.

1. I am the parent/guardian of above named patient. I agree to participate in a telemedicine evaluation. By signing this agreement, I authorize the electronic transmission of my medical information and/or videoconference session so that it can be viewed by a doctor and other persons involved in my medical or mental health care. [Note: The likelihood of this transmission being intercepted by persons other than those at the consulting site is extremely small].

2. I understand that I can withdraw my permission at any time and that I do not have to answer any questions that I consider to be inappropriate or am unwilling to have heard by other persons. I understand that if I do not choose to participate in a telemedicine session, no action will be taken against me that will cause a delay in my care and that I may still pursue face-to-face consultation. I understand that medical records of telemedicine services will be kept at our facility in the same format as records of in-person visits.

3. I understand that each telemedicine visit will be scheduled and that each videoconference session will be initiated by the physician office only. I understand that Dr. Wongsa and the office staff will NOT be monitoring our telecommunications platforms for urgent medical questions. All medical questions should be directed to our phone number 281-897-1122.

4. I understand that as with any technology, telemedicine does have its limitations. There is no guarantee, therefore, that this telemedicine session will eliminate the need for me to see Dr. Peggy Wongsa or other medical specialists in person.

5. I understand that telemedicine only works with certain kinds of visits/conditions. Dr. Wongsa will be the sole decider on what kind of condition may be evaluated or treated through telemedicine.


Telemedicine Fees


I agree to the current telemedicine fee. (Please contact a staff member for the current fee schedule.) I agree to make the payment for this service over the phone by credit card prior to each telemedicine session.

Please select agree even if you are using insurance or Medicaid. See below.

Patients using Insurance: We will attempt to verify telemedicine benefits with your insurance plan before the scheduled visit; however, the benefits quoted may not match the true coverage. Any differences in allowable amounts and the patient responsibility will be billed or refunded to you after the claim has processed.

*** You may be billed for additional amounts after the visit according to how your insurance plan processes the claim. ***


Medicaid Patients: Telemedicine is a covered benefit of Texas Medicaid. However, if the patient is not eligible at the time of service, the patient must agree the pay the self-pay amount of the service. We will bill your Medicaid plan for the telemedicine service. If the adjudication shows the service to be not a covered benefit, you will be responsible for the telemedicine fee.




I have read and understand the information provided above regarding telemedicine, have discussed it with my physician or such assistants as may be designated, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telemedicine in my medical care. I have had an opportunity to review the office's Notice of Privacy Practices.

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