Telehealth Coverage Acknowledgment Form

Patient Name:

Date of Birth:

Date

Due to recent regulatory changes, some telehealth visits are no longer covered by Medicare and several other Insurance Plans, which are listed below.
If you still like to be seen virtually and do not qualify for coverage, the visit will be considered a non covered service.
In such cases, you will be responsible for the cost of the visit and will be paid before the appointment. We cannot bill for these services.
Initial Office Visit 250.00
Follow Up Visit 75.00
An Advance Beneficiary Notice (ABN) will be provided for your acknowledgment before your telehealth appointment.
This policy applies to:

Medicare
Managed Medicare
TriCare West
Blue Cross and Blue Shield Federal
Medicaid patients

Patient Acknowledgment:

I wish to proceed with a telehealth visit and accept responsibility for payment if it is not covered.

I do not wish to proceed with a telehealth visit.

Patient Signature:

Date