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  2. Telemedicine Consent Form

Telemedicine Consent Form

Please Fill Out The Form Below
Care Provider





Patient




Mailing Address




Min: 1 Max: 5








Race

Responsible Party




Mailing Address




Min: 1 Max: 5








Emergency Contact

(Not in the household)




Clinic Policy

All Professional Services Rendered are charged to the patient. Necessary Forms will be completed to help expedite Insurance Carrier Payments however the patient is responsible for all fees regardless of insurance coverage. Private pay telemedicine visits will be billed at $20.00.

Patient Authorization

I authorize the release of any medical information necessary to process my claims. I permit a copy of this authorization to be used in place of an original. I authorize Pampa Medical Group to apply for benefits on my behalf for services rendered by them or by this order. I request payment from my insurance be paid directly to Pampa Medical Group. I certify that the information I have reported with regard to my insurance coverage is correct and I will pay any unpaid balance by my insurance company within 10 days of receiving a bill from Pampa Medical Group.

Pampa Medical Group may leave messages on my:


Acceptance & Patient/Parent/Guardian Signature




optional
Required Fields