Telemedicine e-Visit Request Form

Telemedicine e-Visit Request Form
Patient Name (As written in your credit/bank card)
First NameMiddle NameLast Name
Date of Birth
MonthDayYear
Date
Phone Number
Area CodePhone Number
Email
example@example.com
Skype ID
How can we help you with this e-Visit?

Who would you like to have an e-Visit with?
When would you like to make an appointment?
Do you have a health insurance?
Insurance Company AInsurance Company BNo
Self-pay Policy:
The cost for e-Visit is $50 per visit.
If we are unable to help you after checking your condition, we assure you that you will receive your money back in 30 days.
Insurance Company A Policy:
Insuarance Company A will provide 75% of your payment. The amount that you will pay for e-Visit is $12.50 per visit.
If we are unable to help you after checking your condition, we assure you that you will receive your money back in 30 days.
Insurance Company B Policy:
Insurance Company A Policy:
Insuarance Company A will provide 50% of your payment. The amount that you will pay for e-Visit is $25.00 per visit.
If we are unable to help you after checking your condition, we assure you that you will receive your money back in 30 days.
Please fill the table below.
Yes No Frequency Comment
Smoke or Vape
Alcohol
Recreational Drugs
Medical History

Office Policies
Agreements and Terms

I guarantee the information I have given to you is correct. I give permission to insurance companies or their providers for the disclosure (including Medicare) of medical details required to process insurance claims for the purpose of filing and payment of medical claims. I approve payment by the provider of the medical benefits.
Insurance Information

All services require payment at the time they are delivered. The corresponding co-payments and deductibles must be paid at the time of service.
e-Visit Consent

The COVID-19 (Novel Coronavirus) viral disease was declared as a pandemic by The World Health Organization (WHO) on March 11, 2020. As a result of this rapidly evolving emergency, the need to treat patients are shifting online platform, which will be managed by the practice patterns for physicians, physician assistants, and nurse practitioners.

HIPAA

Under the Federal Health Insurance Portability and Transparency Act, patients over 18 years old are covered. This Federal Policy forbids any of Belaray Dermatology's staff members from sharing treatments, drugs, test results or treatment plans with someone other than the patient. Sometimes, this creates difficulties in accessing details for certain patients who would like family members or caregivers. If you want to encourage someone to address your medical condition, confirm appointments or get results for you, please mention their name(s) below. Details will be given only to certain individuals.
Date of Sign
MonthDayYear
Date
Name
First NameMiddle NameLast Name
Signature
Clear
Should be Empty:

Office Policies