The below named patient/guardian gives consent for Telephone visits and understands that “telephone” is a non-visual telephone connection between the established patient/guardian and the provider. The patient/guardian understands the risks and benefits of a Telephone visit, including:
1) that provider will do their best to provide reasonable medically necessary determination and treatment based on the patient’s/guardian’s Telephone interview, history, and available test results, and medical records;
2) the limitation of Telephone is that the provider is not providing an in-person live examination, or a Telehealth video examination, by the provider. The patient/guardian understands, acknowledges, and accepts:
- Patient/Guardian does not have the ability to conduct a Telehealth visit due to not having a reliable internet access and/or no access to a technology device with which to conduct a telehealth visit (computer, smart phone or tablet).
- This virtual/telephone visit is intended to take the place of a face-to-face visit.
- The covered service being provided is clinically appropriate to be delivered via virtual/telephonic communication and does not require the physical presence of the patient/guardian.
- This virtual/telephone visit is a covered benefit.
- This virtual/telephone visit is medically necessary.
- This covered benefit is clinically appropriate to be delivered via virtual/telephone communication.