Informed Consent - Encounter Telehealth

Click here to download our Informed Consent Policy.

"*" indicates required fields

Patient Name*

Facility*

I consent to the following services to be provided by Encounter Telehealth:*

Medication Management

Mental Health Therapy

Both

Patient/Patient's legal representative, please initial each of the following:*

I have read the TELEHEALTH INFORMED CONSENT DOCUMENT carefully and my questions have been answered to my satisfaction.

I certify that I have read, understand and agree to the PATIENT FINANCIAL RESPONSIBILITY AND BILLING AGREEMENT. The undersigned is the Patient or is duly authorized by or on behalf of the Patient to read and sign this agreement. (We will file all claims for our services to the patient with Medicare and Medicaid. Any deductible, co-pay or other amount not covered by Medicare, Medicaid or patient’s Medicare supplemental insurance, if any, is the responsibility of Patient or Patient’s responsible party and will be billed by us to Patient or Patient’s responsible party and will be billed by us to Patient or Patient’s responsible party. Payment is due upon receipt of billing.

I received a copy of Encounter Telehealth’s NOTICE OF PRIVACY PRACTICE which are effective as of January 1, 2016.

I requested and received a copy of the Telehealth Informed Consent Document, the Patient Financial Responsibility and Billing Agreement, and the Notice of Privacy Practice.

Patient or Legal Representative*

Printed Name:*

Signature:*

Date*

Witness Securing Consent:

Printed Name:*

Signature*

Date*

Phone

This field is for validation purposes and should be left unchanged.