1200 Binz St. Ste 1495 Houston TX 77004 US

10907 Memorial Hermann Dr. Ste 300 Pearland TX  77584 US

Office hours:  Monday-Friday 8:00am-4:30pm    

+1.7136405477       Fax +1.7136405872



Telehealth Consent

Consent For Telehealth

What it is

Telehealth 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.

Examples of telehealth that can be charged to your insurance:

-Televisits-The provider must use an interactive audio and video telecommunications system that permits real-time communication between the distant site and the patient at home.  These visits are considered the same as in-person visits. The coinsurance and deductible would generally apply to these services.

-E-visits- In all types of locations including the patient’s home, and in all areas (not just rural), established patients may have non-face-to-face patient-initiated communications with their doctors without going to the doctor’s office by using online patient portals.

-Virtual visits- In all areas (not just rural), established patients in their home may have a brief communication service with practitioners via a number of communication technology modalities including synchronous discussion over a telephone or exchange of information through video or image.


I understand that Rheumatology Center Of Houston is offering telehealth services as an adjunct to the standard office visits.   I understand that the same standard of care applies to a teleheatlh visit as applies to an in-person visit.

I understand that I will not be physically in the same room as my health care provider.  I also understand other individuals may be present to operate the video equipment and that they will take reasonable steps to maintain confidentiality of the information obtained.

I understand that there are potential risks to using technology, including service interruptions, interception, and technical difficulties.

If it is determined that the videoconferencing equipment and/or connection is not adequate, I understand that my health care provider or I may discontinue the telemedicine visit and make other arrangements to continue the visit.

I understand that a limited physical examination will take place during the videoconference and that I have the right to ask my healthcare provider to discontinue the conference at any time.  I understand that some parts of the exam may be conducted by individuals at my location at the direction of the consulting health care provider

I understand that with telehealth visits, delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment.
In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information.

In rare cases, a lack of access to complete medical records may results in adverse drug interactions or allergic reactions or other judgement errors.

In addition to televisits used at times in place of office visits, my provider at Rheumatology Center Of Houston may also use the telephone or patient portal to address my issues.  I understand a fee may apply for certain telephone visits with the provider.

I understand that I have the right to refuse to participate or decide to stop participating in a telehealth 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.

I may revoke my right at any time in writing, forwarded to Rheumatology Center Of Houston at fax 713-640-5872 or 1200 Binz St Ste 1495 Houston, TX  77004.

I understand that the laws that protect privacy and the confidentiality of health care information apply to telehealth services.

I understand that my health care information may be shared with other individuals for scheduling and billing purposes.

I understand that my insurance carrier will have access to my medical records for quality review/audit.

I understand that this document will become a part of my medical record.

I hereby release Rheumatology Center Of Houston, its personnel and any other person participating in my care from any and all liability which may arise from the taking and authorized use of such videotapes, digital recording films and photographs.

Financial Responsibility

I understand that I will be responsible for any out-of-pocket cost such as copayments or coinsurances that apply to my telehealth visit.

I understand that health plan payment policies for telehealth visits may be different form policies for in-person visits and I will be responsible for calling my insurance to obtain coverage information.

I agree to pay, in a timely manner, for telehealth services.  I authorize payments directly to Rheumatology Center Of Houston for all benefits payable. I understand that I am fully responsible for any unpaid bills not covered by my insurance.

**Special Notice During COVID-19 Pandemic

On March 17, the Centers for Medicare & Medicaid Services (CMS) expanded access to telehealth services as part of the government-wide effort to ease the growing COVID-19 pandemic. The 1135 waiver authority and Coronavirus Preparedness and Response Supplemental Appropriations Act included a provision to waive telemedicine restrictions for Medicare beneficiaries.

Additionally, the Office of Civil Rights (OCR) will not impose penalties on rheumatologists and rheumatology healthcare professionals who use everyday communications technologies such as FaceTime or Skype that are noncompliant with regulatory requirements under the Health Insurance Portability and Accountability Act (HIPAA) during the nationwide pandemic.  Telehealth and virtual care solutions will:  •Improve access to care; •Facilitate the timely diagnosis and treatment of rheumatic patients, while limiting the risk of person-to-person spread of the virus; •Allow providers to communicate with patients anywhere and anytime; •Track patient health status, and •Provide timely interventions.  

Effective March 30, CMS adjusted their payment policy to allow reimbursement for telephone services which will allow rheumatologists and rheumatology providers to provide virtual and eVisits to patients. CMS previously required the consultation have both audio and visual elements.  Some providers may offer phone-only evaluations, especially if your internet connection doesn’t allow for a video chat.  Some insurers do not reimburse for phone visits.  The lack of video further reduces your provider’s ability to perform an exam, which remains a cornerstone of medical care, so this is typically the least preferred method of communication, but it may be better than nothing in some circumstances.

Events are evolving daily around COVID-19. Please continue to check with your insurance for any plan modifications.

If the patient is under the age of 18 or lacks capacity, the signing party affirms that they are either the parent or legal guardian of such patient and has full legal authority to seek medical assistance on behalf of the patient.