Permission for telehealth visit

Permission for Telehealth Visits

What is telehealth?

Telehealth is away to visit with healthcare providers, such as your doctor or nurse practitioner remotely by means of telecommunications technology. 

You can talk to your provider from any place, including your home. You don’t go to a clinic or hospital. 

How do I use telehealth?

· You talk to your provider by phone, computer, or tablet. 

· Sometimes, you use video so you and your provider can see each other.

How does telehealth help me?

· You don’t have to go to a clinic or hospital to see your provider.

· You won’t risk getting sick from other people.

Can telehealth be bad for me?

· You and your provider won’t be in the same room, so it may feel different than an office visit. 

· Your provider may make a mistake because they cannot examine you as closely as at an office visit. (We don’t know if mistakes are more common with telehealth visits.)

· Your provider may decide you still need an office visit. 

· Technical problems may interrupt or stop your visit before you are done. 

Will my telehealth visit be private?

· We will not record visits with your provider. 

· If people are close to you, they may hear something you did not want them to know. You should be in a private place, so other people cannot hear you. 

· Your provider will tell you if someone else from their office can hear or see you.

· We use telehealth technology that is designed to protect your privacy. 

· If you use the Internet for telehealth, use a network that is private and secure. 

· There is a very small chance that someone could use technology to hear or see your telehealth visit. 

What if I want an office visit, not a telehealth visit? 

For now, almost all visits are by telehealth. You cannot schedule an office visit now.

What if I try telehealth and don’t like it?

· You can stop using telehealth any time, even during a telehealth visit. 

· At this time we do not accepting physical visits.

· If you decide you do not want to use telehealth again:

1. Send an email to telemednightingales2@gmail.com

2. It will be as if you never signed this form.

How much does a telehealth visit cost? 

· $37 and up

· A telehealth visit will not cost any more than an office visit. 

Do I have to sign this document?

No. Only sign this document if you want to use telehealth.

Do not sign this form until you start your first telehealth visit. Your provider will discuss it with you.

What does it mean if I sign this document?

If you sign this document, you agree that:

· We talked about the information in this document.

· We answered all your questions.

· You want a telehealth visit.

Please complete the form below and type your name for your signature. Thank you

Insurance:  

No one will be denied access to services due to inability to pay and 2) there is a discounted/sliding fee schedule available?