Informed Consent for Telemedicine Services
Telemedicine involves the use of electronic communications to enable health care providers at different locations to share individual patient medical information for the purpose of improving patient care.
Providers may include primary care practitioners, specialists, and/or subspecialists. The information may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:
- Patient medical records
- Medical images
- Live two-way audio and video
- Output data from medical devices and sound and video files
Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.
Expected Benefits:
- Improved access to medical care by enabling a patient to remain in his/her physicians office (or at a remote site) while the physician obtains test results and consults from healthcare practitioners at distant/other sites.
- More efficient medical evaluation and management.
- Obtaining expertise of a distant specialist.
Possible Risks: As with any medical procedure, there are potential risks associated with the use of telemedicine. These risks include, but may not be limited to:
- In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the physician and consultant(s);
- Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment;
- In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information;
- In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors;
By signing this form, I understand the following:
- I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine, and that no information obtained in the use of telemedicine which identifies me will be disclosed to researchers or other entities without my consent.
- I understand that I have the right to withhold or withdraw my consent to the use of
telemedicine in the course of my care at any time, without affecting my right to future care or treatment.
- I understand that I have the right to inspect all information obtained and recorded in the
course of a telemedicine interaction, and may receive copies of this information for a reasonable fee.
- I understand that a variety of alternative methods of medical care may be available to me, and that I may choose one or more of these at any time. My physician has explained the alternatives to my satisfaction.
- I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.
- I understand that it is my duty to inform my physician of electronic interactions regarding my care that I may have with other healthcare providers.
- I understand that I may expect the anticipated benefits from the use of telemedicine in my
care, but that no results can be guaranteed or assured.
Patient Consent To The Use of Telemedicine
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 hereby authorize Regency Physicians and a member of his or her staff to use telemedicine in the course of my diagnosis and treatment.
CONSENT FOR TREATMENT, ASSIGNMENT OF BENEFITS, AND FINANCIAL POLICIES
I. Consent for treatment: I authorize Regency Skin Institute PLLC; DBA Regency Dermatology and/or Mussman PLLC; DBA Regency Plastic Surgery its agents, Betty Hinderks Davis, MD Jason Mussman, MD, Benjamin Jones , MD, Brent Schultz, MD,Zoe MacIsaac, MD, Stephanie Spahr, PA-C & Brittany Silverman, PA-C to render treatment to me/my dependents for dermatological and medical/surgical care.
II. Assignment of Benefits/Release of medical information: I request that payment for authorized Medicare or other applicable private insurance benefits be paid directly to Regency Skin Institute PLLC; DBA Regency Dermatology and/or Mussman PLLC; DBA Regency Plastic Surgery for services provided under their care. I also authorize Regency Skin Institute PLLC; DBA Regency Dermatology and/or Mussman PLLC; DBA Regency Plastic Surgery to release necessary medical information to my insurance company, its agents, or any third party in order to determine pa
**Once your deductible is met, many insurance companies still do not pay 100% of the healthcare cost. If that is the case you will have a copay or co-insurance, which is a partial payment required by you in addition to what the insurance company will pay. It can be from 10-50% of the allowed amount until you have accumulated enough medical bills to meet your yearly out-of-pocket maximum.
***This is an estimated portion that is due. Unfortunately we don’t know exactly what your insurance will cover or what you will be billed until your claim is processed.
If you have any questions regarding your financial responsibilities please ask or call our billing department at Regency Dermatology: 623-243-9077 Regency Plastic Surgery: 623-322-0730
V. Referrals/Authorization: I understand that if my insurance company requires a referral, I am responsible for obtaining a referral prior to my visit. If I do not have a referral at the time of service, no services will be rendered until I obtain a referral or sign a waiver of financial responsibility. Payment in full is required at the time of service.
VI. Missed Appointments: Our office requires 24 hour notice for cancellations. Patients who fail to show to the initial visit will be forgiven, If a patient chooses to schedule a second appointment we will place a credit card on file and If the second appointment is missed we will process the credit card on file for $75.00 (non refundable). If a third no show or cancellation/reschedule with no 24 hour notice should occur the patient will be charged $90.00. If a fourth should occur the patient will be charged $100.00 and be dismissed from Regency Skin Institute PLLC; DBA Regency Dermatology and/or Mussman PLLC; DBA Regency Plastic Surgery.
I have reviewed the statements above and understand my responsibilities.
HIPAA COMPLIANCE STATEMENT
THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
At Regency Skin Institute PLLC; DBA Regency Dermatology and/or Mussman PLLC; DBA Regency Plastic Surgery we are committed to protecting your privacy. We comply with all federal, state, and local laws. This notice describes how we use your health information. It describes some of your rights and some of our responsibilities.
UNDERSTANDING YOUR HEALTH RECORD/INFORMATION
Each time you visit our offices, we record your symptoms, physical examination, test results, diagnosis, and treatment. This information enables us to: plan for your care, communicate with others who care for you, report to your insurance carrier, bill for our work, and improve the quality of our care.
YOUR RIGHTS
Although your paper chart belongs to our practice, the information contained in the chart is yours. You have the right to: inspect your records, obtain a copy of your chart for a small fee, correct your records, and tell us not to release your information.
OUR RESPONSIBILITIES
We are required to: maintain the privacy of your health information; send needed health information to other medical providers, and release information to insurance companies, certain government agencies, and others. We may be required to release some information, even without your permission.
OTHER NOTICES
We may leave a message at your home, at your business, on your answering machine or on your voicemail. We may mail you a postcard or other written notices. We may need to disclose your information to your family members or other people helping with your care. In doing so, we will use our best judgment. We may disclose information to others as required by law or if subpoenaed. If you were injured on the job, we will need to disclose your health information to your workers compensation insurance company. We may, from time to time, update these policies.
FOR MORE INFORMATION OR TO REPORT A PROBLEM If you have concerns or would like additional information, you may contact the practice’s Office Manager at (623)243-9077.
Financial Disclosure
A physician must notify a patient that the physician has a direct financial interest in a separate diagnostic or treatment agency to which the physician is referring the patient and/or in the non- routine goods or services being prescribed by the physician, and whether these are available elsewhere on a competitive basis. A.R.S. §32-1401(27)(gg). (I/We) support this law, because it helps patients make reasoned financial decisions concerning their medical care.
You are being referred to/from (Regency Dermatology/Regency Plastic Surgery) to (Regency Dermatology/Regency Plastic Surgery). While A.R.S. §32-1401(27)(gg) may not directly apply depending on the referral source, (I/we) wish to advise you of Dr. Mussman’s financial interest in these entities so that you can make an informed decision about your care.
Regency Dermatology is a trade name owned by Regency Skin Institute, PLLC. Dr. Jason L. Mussman owns, controls and has a financial interest in Regency Skin Institute, PLLC.
Regency Plastic Surgery is a trade name owned by Mussman, PLLC. Dr. Jason L. Mussman, as Co-Trustee of the Mussman Family Living Trust, owns, controls and has a financial interest in Mussman, PLLC.
Further, as indicated below, goods or services (I/We) have prescribed are available elsewhere on a competitive basis.
THESE SERVICES AVAILABLE ELSEWHERE ON A COMPETITIVE BASIS
Dermatology
- Beatrice Keller Dermatology
- Omni Dermatology
- Affiliated Dermatology
Plastic Surgery
- Biswas Plastic Surgery
- Richard J Brown Plastic Surgery
Surgery Centers and Hospitals
- Estrella Outpatient Surgery Center
- Abrazo West Hospital
- Banner Del Webb Hospital
The law provides for the acknowledgement of your having read and understood these disclosures by dating and signing this form in the spaces provided below. (I/We) will keep the signed original in your patient file; you will receive a copy.
ACKNOWLEDGEMENT: (I/We) have read this “Notice to Patients” form, and (I/We) understand the disclosures that it contains.
