Telehealth Consultation Consent

Telehealth consultation consent form

You are scheduled to have a telehealth consultation.

This service will be bulk billed,using the following new Medicare item numbers:

For Consult less than 20 minutes For Consult 20 – 40 minutes

Item Number: 91800 Item Number: 91801

Benefit Amount: $38.20 Benefit amount: $73.95

Agreement

If you (the patient) agree to the assignment of the Medicare benefit directly to the Doctor (bulk bill), please agree to the below.

I agree to the assignment of the Medicare benefit directly to the provider

Yes

Patient Nameyour full name

DOByour date of birth

Date of scheduled consult

Medicare Number

Your time is always respected. You’ll never feel rushed and have all your questions answered. Contact us today to schedule your first appointment!