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Definition of Telehealth

Telehealth involves the use of electronic communications to enable Beacon Orthopaedics & Sports Medicine’s providers to connect with individuals using interactive video and audio communications.

Telehealth includes the practice of health care delivery, diagnosis, consultation, treatment, referral to resources, education, and the transfer of medical and clinical data.

Informed Consent for Telehealth Services

I understand the following information with respect to telehealth:

1. The state and federal laws that protect the confidentiality of my personal information also apply to telehealth. I also understand that the dissemination of any personally identifiable images or information from the telehealth interaction to other entities shall not occur without my written consent unless specifically allowed or required by law.

2. I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment.

3. I understand that the telehealth transmission of my personal information may be disrupted or distorted by technical failures that are beyond the control of my health care provider. Beacon utilizes secure, encrypted audio/video transmission software to deliver telehealth, but we cannot guarantee that a third-party will not be able to illegally intercept the telehealth transmission.

4. I understand that all orthopaedic evaluations cannot be completed remotely. If my provider believes I would be better served by in-person evaluation and treatment, I will be asked to come to a practice location to receive care.

5. I understand the alternatives to telehealth as they have been explained to me. In choosing to participate in telehealth, I am agreeing to participate using video conferencing technology. I also understand that at my request or at the direction of my provider, I may schedule a “face-to-face” evaluation.

6. I understand that anticipated benefits of telehealth include improved access to care as well as more efficient evaluation and management of my care, but that no results can be guaranteed or assured.

Payment for Telehealth Services

Beacon will bill insurance for telehealth services when these services have been determined to be covered by an individual’s insurance plan. 

Patient Consent to the Use of Telehealth

I have read and understand the information provided above regarding telehealth; I have discussed it with my provider’s clinical team; and all my questions have been answered to my satisfaction.

I hereby give my informed consent to participate in telehealth services for treatment as described above.

I certify that I have read, understood, and agree to the terms of this treatment agreement.

I acknowledge that I have been provided with and understand this facility’s Notice of Privacy Practices (HIPAA information). This notice provides a complete description of the uses and disclosures of my health information.

*If the patient is a minor child or otherwise unable to sign this authorization, then obtain the signature of the authorized individual.

Effective April 2009

Beacon Orthopaedics and Sports Medicine, LLC (BOSM) believes that in the interest of good health care practices, it is best to establish a patient financial/credit policy between our patients and ourselves in order to avoid any misunderstandings. Our Account Representatives will be glad to discuss your account with you at any time and set up payment plans. Our primary responsibility is to deliver quality health care services.  We wish to spend our time and energy toward that responsibility.  We expect you to show us the same consideration as you do your other creditors, and to be honest and forthright regarding your financial responsibility.

(By signing you agree to all terms below)

1.) We expect that all co-pays, co-insurance and deductible be paid in full at each visit and prior to surgery, diagnostic testing and physical therapy. We accept cash, check, Debit Card, MasterCard, VISA, American Express, Discover and Care Credit.

2.) We file claims to your insurance company for your primary and secondary policies. You must bring your insurance card with you to every visit and make us aware of any change in coverage. We also require a copy of your driver’s license to confirm identity. Please remember insurance coverage is a contract between the patient and the insurance company. When BOSM files for benefit for services performed, benefits are assigned to BOSM. BOSM will look to the patient for payment in full if insurance does not cover the services provided. If we do not participate with your insurance, you will likely have a higher out-of-pocket expense, so please be prepared to pay this amount.

3.) We do not file any insurance with your Automobile Insurance Company, or any other third party (business insurance company, employer, attorney, separated spouses, etc.) for the purpose of obtaining payment. We will make every effort to provide you with proper documentation for you to receive reimbursement from those parties (i.e., claim form, statement or report). Please speak with our billing representative. We do not accept Letters of Guarantee or other promises to pay when cases settle. You will be extended credit only if arrangements are made in advance and only within our standard guidelines for credit.

4.) If the patient is under age 18, a parent or guardian must sign below. If the minor does not reside with both parents, and there is a dispute over which parent is responsible for any remaining balances, we will ultimately rely upon the parent/guardian who brought the child to the office for financial responsibility. All minors will not be seen unless accompanied by a guardian or a signed authorization from that guardian allowing our physicians to provide medical treatment.

5.) A service charge of $20.00 will be applied to returned checks. You will be asked to bring cash, money order or cashiers check to our office to cover the amount of the check plus the service charge. If you present two (2) checks that are returned to us, we will require cash for future services.

6.) If your balance is not paid in a timely manner, we reserve the right to forward your account to an outside collection agency or attorney. All fees assessed by the agency or attorney will be charged to you and become a part of your outstanding balance.

By signing this agreement, you are acknowledging that you understand our financial/credit policy and agree to pay for all services that are received.