Telehealth Clinical Evals
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  First Name:
Last Name:
Address / Street:
  City:
  State:
  Zip:
  Phone: () -
  Date of Birth:
  Gender:
Email:
  Do you have Home Health?
Equipment Provider:
  ATP Name:
  Primary Insurance: Provider:    Group #:    Member ID:
  Secondary Insurance: Provider:    Group #:    Member ID:
 
  Patient Acknowledgement & Medical Release To Obtain Medical Records
 
  • I understand I have a choice of who provides my healthcare and have chosen practitioners (physicians and therapists) to perform my medical evaluation as required for prescribed equipment, supplies and services.
  • I hereby authorize and request the release of my Personal Health Information (PHI) by Medical Practice in addition to any other of my medical care providers, emergency contact person/s, hospitals facilities or other third party institutions to for the purpose of medical services:
  Entire record:
  Entire record except: Mental health records
    Communicable diseases (including HIV and AIDS)
    Alcohol / drug abuse treatment
  Other, please explain:
  • I understand this consent is effective on the date I sign it. It may be revoked at any time by delivering written notice to and the revocation will be effective as of the date received, except to the extent has taken action in reliance of this consent. This consent is valid for one year from the effective date.
  • Information disclosed pursuant to the authorization may be re-disclosed by the recipient and no longer protected by the federal privacy regulations
  • I understand that I have the right to refuse to give this consent
  • I acknowledge that I have received a copy of the Provider Notice of Privacy Practices as required by the Health Information Portability and Accountability Act (HIPAA). I understand that upon completion of reading the notice, any questions I may have may be addressed to the Provider.
  • I acknowledge that I have received all Patient Handouts (Click here to download) including Patient Rights, and I understand that I have a choice of clinician to perform my evaluations. I acknowledge that I have chosen to perform my evaluation.
  • I authorize the release of any medical or other information necessary to process my Health Insurance Claim. I also request payment of government benefits either to myself or to the party who accepts assignment on my Health Insurance Claim.
  • I authorize payment of medical benefits to for services described on my Health Insurance Claim.
  Patient Consent to Telehealth
  • I agree to be treated via a Telehealth Video and/or Audio Conference visit and acknowledge that I may be liable for any relevant co-pay or coinsurance depending on my insurance plan.
  • I understand that this Telehealth Video and/or Audio Conference visit is offered for my convenience and I am able to cancel and reschedule with a different practitioner for an in-person appointment if I desire.
  • I also acknowledge that sensitive medical information may be discussed during this Telehealth Video and/or Audio Conference visit appointment and that it is my responsibility to locate myself in a location that ensures privacy to my own level of comfort.
  • I also acknowledge that I should not be participating in a Telehealth Video and/or Audio Conference visit in a way that could cause danger to myself or to those around me (such as driving or walking.) If my provider is concerned about my safety, I understand that they have the right to terminate the visit.
  Signer is Beneficiary:
  Beneficiary or
Representative Signature:
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Therapist Registration

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