Telehealth and Consent to Treat Forms, Cancellation Policy, and Release of Information for Insurance


(If child under 18)

 A: Informed Consent for Telehealth Services

One or more of your appointments at Learning Solutions may be telehealth appointments (held over Zoom or Doxy). In such cases, you need to use a webcam or smartphone. It is important to be in a quiet, private space that is free of distractions (including cell phone or other devices) during the session. It is important to use a secure internet connection rather than public/free Wi-Fi. It is important to be on time. If you need to cancel or change your tele-appointment, you must notify the Learning Solution’s staff member in advance by phone or email (see our cancellation policy above). In the event of technical problems, we may need to call you by phone, or reschedule the meeting.

If you are not an adult, we need the permission of your parent or legal guardian (and their contact information) for you to participate in telehealth sessions. Confidentiality still applies for telehealth services, and nobody will record the session without the permission from the other person(s). You should confirm with your insurance company that the video sessions will be reimbursed; if they are not reimbursed, you are responsible for full payment.

 

B: Consent to Treat

By signing below, you are providing consent for us to provide treatment to   and are affirming that you are legally authorized to consent to such treatment. (If you do not sign this consent form, we cannot treat you/your child.) After you have signed this consent, you have the right to revoke it, in writing received by us, and we will not provide further treatment from that time on, but we may already have provided treatment and cannot change that.

 

C: Cancellation Policy

  • Appointments canceled with less than 48-hour notice will be charged to me at $90.
  • Secondary insurance will be billed as a courtesy, but I am responsible for the entire balance of services performed regardless of whether there is insurance coverage.

 

D: Release of Information and Assignment of Benefits for Insurance

 

 

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Document name: Telehealth and Consent to Treat Forms, Cancellation Policy, and Release of Information for Insurance
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October 19, 2021 7:58 am ESTTelehealth and Consent to Treat Forms, Cancellation Policy, and Release of Information for Insurance Uploaded by Leslie Roberts - learningsolutions@learningsolutionsls.com IP 96.39.16.94
October 19, 2021 8:21 am EST Document owner joanne@joannepinatel.com has handed over this document to learningsolutions@learningsolutionsls.com 2021-10-19 08:21:49 - 96.39.16.94