teleHealth consent form


Please review this consent form and fill in the acknowledgement sections at the bottom to go to the Pocket Patient App page.


Telehealth is healthcare provided by any means other than a face-to-face visit. In telehealth services, medical health information is used for diagnosis, consultation, treatment, therapy, follow-up, and education. Telephone consultation, videoconferencing, transmission of still images, e-health technologies, patient portals, and remote patient monitoring are all considered telehealth services.

I understand that telehealth involves the communication of my medical health information in an electronic or technology-assisted format.

I understand that I may opt out of the telehealth visit at any time. This will not change my ability to receive future care at this office.

I understand that telehealth billing information is collected in the same manner as a regular office visit. My financial responsibility will be determined individually and governed by my insurance carrier(s), Medicare, or Medicaid, and it is my responsibility to check with my insurance plan to determine coverage.

I understand that all electronic medical communications carry some level of risk. While the likelihood of risks associated with the use of telehealth in a secure environment is reduced, the risks are nonetheless real and important to understand.

I understand that medical information, including medical records, are governed by federal and state laws that apply to telehealth. This includes my right to access my own medical records (and copies of medical records). I understand that Skype, FaceTime, or a similar service may not provide a secure HIPAA-compliant platform, but I willingly and knowingly wish to proceed. The healthcare provider is not responsible for breaches of confidentiality caused by an independent third party or by me.

I understand that I have a responsibility to verify the identity and credentials of the healthcare provider rendering my care via telehealth and to confirm that he or she is my healthcare provider.

I understand and agree that a medical evaluation via telehealth may limit my healthcare provider's ability to fully diagnose a condition or disease. As the patient, I agree to accept responsibility for following my healthcare provider's recommendations-including further diagnostic testing, such as lab testing, a biopsy, or an in-office visit.

I understand that my healthcare provider may choose to forward my information to an authorized third party. Therefore, I have informed the healthcare provider of any information I do not wish to be transmitted through electronic communications.

By signing below, I understand the inherent risks of errors or deficiencies in the electronic transmission of health information and images during a telehealth visit.

I understand that there is never a warranty or guarantee as to a particular result or outcome related to a condition or diagnosis when medical care is provided. To the extent permitted by law, I agree to waive and release my healthcare provider and his or her institution or practice from any claims I may have about the telehealth visit.

I understand that electronic communication should never be used for emergency communications or urgent requests. Emergency communications should be made to the provider's office or to the existing emergency 911 services in my community.

National Emergency Crisis Language Insurance Assignment
The undersigned, certify that I (or my dependent) have insurance coverage and assign directly to Skin and Cancer Associates (SCA) all insurance benefits, if any, otherwise payable to me, for services rendered. I hereby authorize SCA to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions. I understand that I am responsible for my health insurance deductibles and coinsurance.

If you have insurance which will pay our doctor directly, and which we can verify, we still require that you pay all co-payments, deductibles, co-insurance and charges for non-covered services at the time of service.

I acknowledge that I was informed of the Notice of Privacy, located on our website: