Ann Shippy, MD

Available Forms

Authorization for Use and Disclosure of Protected Health Information Female Intake Form Informed Consent for Telehealth Consultations Insurance Policy Male Intake Form Medicare Private Contract New Patient Cancellation Policy New Patient Letter and Office Policies New Patient Supplement List Newsletter Form Notice of Privacy Practices PATIENT ENROLLMENT AND CONSENT FORM Physician's Records Request List

Informed Consent for Telehealth Consultations

To better serve the needs of people in the community, health care services are now available by interactive video communications and/or by the electronic transmission of information. This may assist in the evaluation, diagnosis, management, and treatment of a number of health care problems. This process is referred to as ?telemedicine? or ?telehealth.? This means that you may be evaluated and treated by a health care provider or specialist from a distant location.

Since this may be different than the type of consultation with which you are familiar, it is important that you understand and agree to the following statements.

1.The consulting health care provider, Ann Shippy, MD will be at a different location from me.

2. I will be informed if any additional personnel are to be present other than myself, individuals accompanying me, and the consulting health care practitioner, Ann Shippy, MD. I will give my verbal permission prior to the entry of the additional personnel.

3.The physician or health care provider for whom the on-site examination or treatment is performed (that is, Ann Shippy, MD) will keep a record of the consultation in my medical record.

4. I understand that it is my responsibility to make arrangements for follow-up care however, Dr. Shippy will provide me with guidance on appropriate follow-up care.

5. I understand that I have the option to refuse telehealth service at anytime without affecting the right to future care or treatment.

6. In consideration for the telehealth services rendered to me, I agree to pay the charges.

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