Your visit and follow-up care may be completed using internet-based technologies commonly referred to as Telemedicine. Telemedicine services involve the use of secure interactive videoconferencing equipment and devices that enable health care providers to deliver health care services to patients while the provider and patient are in different locations.

1. I understand that the same standard of care applies to a telemedicine visit as applies to an in-person visit.
2. I understand that I will not be physically in the same room as my health care provider. I will be notified of and my consent obtained for anyone other than my healthcare provider present in session.
3. I understand that there are potential risks to using technology, including service interruptions, interception, and technical difficulties.
   • If it is determined that the video conferencing equipment and/or connection is not adequate, I understand that my health care provider or I may discontinue the telemedicine visit and make other arrangements to continue the visit.
4. I understand that I have the right to refuse to participate or decide to stop participating in a telemedicine visit, and that my refusal will be documented in my medical record. I also understand that my refusal will not affect my right to future care or treatment.
   • I may revoke my right at any time by contacting the practice administrator at 214-750-9977.
5. I understand that the laws that protect privacy and the confidentiality of health care information apply to telemedicine services.
6. I understand that my health care information may be shared with other individuals for scheduling and billing purposes.
   • I understand that my insurance carrier will have access to my medical records for quality review/audit.
   • I understand that I will be responsible for any out-of-pocket costs such as copayments or coinsurances.
   • I understand that health plan payment policies for telemedicine visits may be different from policies for in-person visits.
7. I understand that this document will become a part of my medical record.

Payment Expected at Time of Service: You must pay any co-payment or deductible at the time of service prior to your appointment date. The insurance portion of your bill will be sent to your insurance company for direct payment to our practice. Any changes or accommodations for this policy must be agreed to in advance.

If your insurance company remits this payment to you, please send it to us along with all paperwork sent to you at that time. Please do not send it back to the insurance company, for this will only delay financial payment that you will be required to pay to our office.

Filing Your Insurance Claim: NCD will file a claim on your behalf with your insurance company. Under the provisions of plans with some companies, your insurance may refuse payment of a claim if: 

1. This is a condition or service in which your insurance does not cover.
2. The type of medical service required is not covered or is considered as “Experimental” by your insurance.
3. The insurance was not in effect at the time of service and you did not provide NCD with your updated insurance coverage within the insurance company filing time limits.
4. Other reasons not listed here.

If your insurance company denies the claim for any reason, our practice will not be responsible for this bill. It is the responsibility of the patient to pay the full amount. Remember, that as a consumer of healthcare services, you are ultimately responsible for payment of your medical expenses. If your account is not settled within 45 days of the date of service, we reserve the right to collect payment from you. If payment is not received within 90 days, we reserve the right to turn your account over to collections and discontinue providing services.

Portal and Phone Messages: We understand that there are times when you or your family may have questions related to your care. The best way to communicate with your care team at NCD is to send a portal message. If you leave a voice message, it may take a little bit longer to get back to you. It may be necessary for us to manage some of your care through portal messages and phone calls. These encounters are billed to your insurance company. In addition, the federal government requires the use of portal messaging to maintain our reimbursement levels.

Last paragraph – By agreeing to these terms of service, I attest that I (1) have personally read this form (or had it explained to me) and fully understand  and agree to its contents; (2) have had my questions answered to my satisfaction, and the risks, benefits, and alternatives to telemedicine visits shared with me in a language I understand. By agreeing to these terms of service, I attest that I (1) have personally read this form (or had it explained to me) and fully understand  and agree to its contents; (2) have had my questions answered to my satisfaction, and the risks, benefits, and alternatives to telemedicine visits shared with me in a language I understand.