We are scheduling a Telemedicine appointment in place of an office visit for your appointment because of the COVID-19 Public Health Emergency. During the visit Dr. Imtiaz will provide the service of evaluating and treating the concern you are being scheduled for and we will bill for this service just like when you have an appointment in the office. Most insurance companies are covering the telemedicine services during this COVID 19 public health emergency, but for specific plan benefits, including patient out of pocket cost, we would encourage you to reach out to your insurance company for more details.
I have attached the consent for Telemedicine appointment at the bottom of this email. By scheduling this appointment, you are giving your consent for us to use voice and video for the purpose of diagnosing and treatment as deemed necessary by Dr. Imtiaz.
During the telemedicine visit, Dr. Imtiaz may decide that you need an in-office appointment at a later time. If you are unable to review this consent, or have any other questions or concerns please call us at 281 463 9100.
Instructions on how to join meeting for your telemedicine appointment:
Please download Skype for Business (regular Skype will not work). You do not need to set up an account; you will be joining as a guest.
At the time of appointment, you will need to open THIS email which contains the link for your visit. At your scheduled time please click on the link, join as guest and enter your name. At that point you will wait until Dr. Imtiaz joins the meeting.
We will call you prior to the meeting time to go over any questions and to collect co-payment
If a telemedicine visit is missed by you, or cancelled less than 48 hours in advance of scheduled visit time, you will be charged a fee of $95
You must hit reply to this email and include “I accept and agree” in your reply to proceed
Please understand that this type of visits is new for all of us. We would love to hear both good and bad from you so that we may improve our service.
We wish you health and happiness.
North Cypress Women’s Center/Dr. Farhina Imtiaz staff
Consent for Telemedicine Services
Telemedicine services involve the use of secure interactive videoconferencing equipment and devices that enable health care providers to deliver health care services to patients when located at different sites.
1. I understand that the same standard of care applies to a telemedicine visit as applies to an in-person visit.
2. I understand that I will not be physically in the same room as my health care provider. I will be notified of and my consent obtained for anyone other than my healthcare provider present in the room.
3. I understand that there are potential risks to using technology, including service interruptions, interception, and technical difficulties.
a. If it is determined that the videoconferencing equipment and/or connection is not adequate, I understand that my healthcare provider or I may discontinue the telemedicine visit and make other arrangements to continue the visit.
4. I understand that I have the right to refuse to participate or decide to stop participating in a telemedicine visit, and that my refusal will be documented in my medical record. I also understand that my refusal will not affect my right to future care or treatment.
a. I may revoke my right at any time by contacting North Cypress Women’s Center at 281-463-9100.
5. I understand that the laws that protect privacy and the confidentiality of healthcare information apply to telemedicine services.
6. I understand that my health care information may be shared with other individuals for scheduling and billing purposes.
a. I understand that my insurance carrier will have access to my medical records for quality review/audit.
b. I understand that I will be responsible for any out-of-pocket costs such as copayments or coinsurance that apply to my telemedicine visit.
c. I understand that health plan payment policies for telemedicine visits may be different from policies for in-person visits.
7. I understand that this document will become a part of my medical record.
By making and confirming this appointment, I attest that:
I have personally read this consent (or had it explained to me) and fully understand and agree to its contents;
have had my questions answered to my satisfaction, and the risks, benefits, and alternatives to telemedicine visits shared with me in a language I understand; and
I am located in the state of Texas and will be in Texas during my telemedicine visit(s).