Direct Connect

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*Please mark the item that best describes the patient’s current telemedicine need/concern:
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*Who is receiving care during this visit?
*Name of supervisor authorizing this visit.
*Employee's name on plan.
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*Has the patient ever been treated by a CoxHealth provider or at a CoxHealth facility?
*Patient Legal Last Name
*Patient Legal First Name
Middle Initial
*Patient Date of Birth (MM/DD/YYYY):
*Gender
*Phone Number where you can be immediately reached.		Ext.
Please provide a phone number for a CoxHealth Telemedicine representative to contact you.
Patient Email address:

The following information is needed to ensure your information is updated in our system for future services.

*Street Address Line 1
Street Address Line 2
*City
*State
*Zip Code
*Insurance Company Name
*Other Insurance Company Name
*Insurance Group Number This information is located on your current Insurance card.
*Insurance Member/Policy Number This information is located on your current Insurance card.

Privacy Statement and Consent

AUTHORIZATION AND CONSENT FORM FOR TELEHEALTH SERVICES
To better serve the needs of our patients and others in the community, CoxHealth Network offers health care services via interactive video communications and/or by the electronic transmission of information. This service will 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 you may be evaluated and treated by a health care provider 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:

I understand the consulting health care provider (“consulting provider”) will be at a different location from me. A provider (“presenting provider”), an employee of CoxHealth who aids in the examination (“telepresenter”) or a representative of my Employer may be present with me to assist in the consultation.
I understand my protected health information may be electronically transmitted to the consulting provider who is at a different location. I understand that this consultation will not be the same as a face-to-face visit since I will not be in the same room as the consulting provider, and that some parts of a physical exam may be conducted by individuals present with me at the direction of the consulting provider.
I will be informed if any additional personnel are to be present other than myself, individuals accompanying me, the presenting provider, the telepresenter and, via video, the consulting provider. I will give my verbal permission prior to entry of any additional personnel.
The health care provider for whom the on-site examination or treatment is performed, the presenting provider, or the telepresenter will keep a record of the consultation in my medical record and I will have access to it.
I voluntarily consent to health care services provided or ordered, which may include diagnostic tests, drugs, examinations, and medical or surgical treatments considered necessary to treat my health problem.
I understand that I may be released before all my medical problems are known or treated and it is my responsibility to make arrangements for follow-up care.
I understand there are possible risks of an incomplete or ineffective consultation because of the technology, and that if any of the risks occur, the consultation may terminate. The risks may include: a) failure, interruption or disconnection of the audio/video connection; b) a picture that is not clear enough to meet the needs of the consultation; and/or c) a minor risk of access to the consultation through the interactive connection by electronic tampering.
I understand that I have the option to refuse telehealth service at any time without affecting the right to future care or treatment and without risk of losing MO HealthNet or workers’ compensation benefits to which I am entitled. I further understand that in place of this telehealth session I may seek a face-to-face consultation with a health care provider.
I understand I have the right to consent to or deny a request for videotaping or other recording of the evaluation.
I release CoxHealth, its employees, agents and assigns from any and all liability which may arise from this telemedicine consultation, the use of interactive audio/visual connections, or from the taking or authorized use of any images or audio obtained.

RELEASE OF INFORMATION/NOTICE OF PRIVACY PRACTICES: The CoxHealth Notice of Privacy Practices sets forth my rights regarding my personal health information and the ways in which it may be used or disclosed. This includes the sharing and/or receiving of prescription information with a prescription database utilized in electronically prescribing medications for my treatment, if applicable. I understand that I have the following rights regarding my information: to receive the Notice of Privacy Practices prior to signing this consent and to revoke this consent in writing, except to the extent that CoxHealth has already taken action in reliance that all representations made by me are true. I authorize the review, copying, release and disclosure of any and all information in my medical or accounting record, including information regarding the diagnosis or treatment of HIV, AIDS, mental illness, or substance abuse, to any person, corporation or agency responsible for determining the necessity, appropriateness, payment or other matters related to the CoxHealth treatment or services rendered to me.

CoxHealth Privacy Policy

I acknowledge that on 5/28/2023, I:

Received

Declined

a copy of the CoxHealth Notice of Privacy Practices.

ACKNOWLEDGEMENT: I have read and understand this consent and all of my questions have been answered to my satisfaction. I understand the risks, benefits, and alternatives of the telehealth consultation and consent to it. I, , give consent for treatment.

By continuing, you accept full payment responsibility if your claim is denied by insurance or your employer.