Www.entsaofappleton.com



EAR, NOSE AND THROAT SURGICAL ASSOCIATES, S.C.1520 N. Meade StreetAppleton, Wisconsin 54911Telephone: (920) 734-7181 * Fax: (920) 734-0621MATTHEW BETTAG, M.D.KENT SCHAEFER, M.D.STEVEN VANDENBERG, M.D. MICHAEL MCAVOY, D.O.TELEMEDICINE PATIENT CONSENT FORMPlease note: To participate you must have: Android or Apple phone or Firefox or Chrome Web browserPATIENT’S NAMEClick or tap here to enter text.DOB:Click or tap here to enter text.I, (name of patient or parent/guardian) Click or tap here to enter text. , agree to participate in a telemedicine evaluation. By signing this agreement, I authorize the electronic transmission of my medical information so that it can be viewed by a doctor and/or any other persons involved in my medical care. 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 evaluation, 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 with any technology, telemedicine does have its limitations. Therefore, there is no guarantee that this telemedicine evaluation will eliminate the need for me to see a specialist in person. I understand that medical records of telemedicine services will be kept at Ear, Nose & Throat Surgical Associates, S.C. I understand that I need to provide Ear, Nose & Throat Surgical Associates, S.C with my current insurance information prior to the start of my appointment. I understand that telemedicine visits will be billed to my insurance company and all out of pocket costs apply (copay/coinsurance/deductible) as deemed applicable by my insurance company. If I do not provide Ear, Nose & Throat Surgical Associates, S.C with accurate/current insurance information, I understand that the full amount of my telemedicine appointment will be my responsibility. If I do not have insurance, I understand that I will be responsible for the self-pay amount prior to the start of my appointment via phone or online portal. I understand that my Personal health information will not be recorded, or data stored by the doxy.me site. I understand that doxy.me is HIPPA compliant. Electronic Signature of patient (or parent/guardian):__Click or tap here to enter text.Date of Electronic Signature:_Click or tap here to enter text._Please print the above name:_Click or tap here to enter text.___ ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download