Orly Avitzur, MD, PC Tele-visit
After reading the Tele-visit terms and conditions below:
Please go to the CONTACT at the top of this page and complete form and under MESSAGE state: I agree to Tele-visit Terms & Conditions.
If you are a NEW PATIENT please complete this REGISTRATION FORM prior to the visit. You will be asked to upload it when you arrive in the Waiting Room. If you have been to the office before, please complete this SHORT UPDATE FORM.
Our Tele-visit Program affords patients the opportunity to complete Tele-visit appointments from the comfort of their own home or any appropriate internet access point. The program is open to select patients who meet the requirements to complete the tele-visit appointments. Those requirements include:
1. Having the technology to support the Tele-visit.
2. Having been seen by me in person within the last 36 months, (if you are an established patient).
At this time, insurance coverage may not be available for this service. Each patient or patient’s guarantor must complete the following acknowledgments:
Insurance: If my insurance does not cover this service, I acknowledge that I waive my right to file a claim with my insurance carrier and will not request that my insurance be charged for this service at a later date. If my insurance does not cover this service, I acknowledge that I have agreed to "self-pay" for these specific Tele-visit services provided to me, and I will be responsible for payment in full at the time of service during the enrollment process.
Requirements: I acknowledge that I have agreed to comply with the requirements of this program and understand that the selection to participate, and continued participation, is subject to the program requirements and periodic review by the treating provider, staff, and administration. I acknowledge that I have read and understand the overview of the Tele-visit provided and that I will provide the appropriate technology to complete the visit, and that this requirement is my responsibility, and that I can provide the equipment, connectivity, and software requirements. I acknowledge that I should be in a secure environment (not a restaurant, lobby, etc.) for the visit, and that it is my responsibility to ensure the privacy of my information on my computer/device.
I acknowledge that I have read and understand the disclaimer, terms and conditions, and privacy policy that apply to the Tele-visit. I acknowledge that the provider conducting the Tele-visit is authorized to determine in advance or during the Tele-visit whether I am or remain eligible for this Tele-visit.
DISCLAIMER
Informed Consent and Terms of Use:
Please indicate your consent to and understanding of the terms and conditions of use of the Tele-visit system before starting your interview with Dr. Avitzur.
I ACKNOWLEDGE THAT TELE-VISITS ARE FOR ROUTINE, NON- URGENT MEDICAL CONDITIONS, AND ARE NOT DESIGNED, INTENDED, OR APPROPRIATE TO ADDRESS SERIOUS, EMERGENT, OR LIFE-THREATENING MEDICAL CONDITIONS. I WILL NOT ATTEMPT TO USE MY TELE-VISIT TO ADDRESS THESE CONDITIONS. IF I AM HAVING A MEDICAL EMERGENCY, I WILL DISCONTINUE MY TELE-VISIT AND CALL 911 OR GO TO THE NEAREST EMERGENCY DEPARTMENT. IF I AM EXPERIENCING SIGNIFICANT PAIN, BREATHING TROUBLE, DEHYDRATION, OR ANY OTHER DISTRESS THAT REQUIRES IMMEDIATE OR URGENT ATTENTION, I WILL DISCONTINUE MY TELE-VISIT AND CALL 911 OR GO TO THE NEAREST EMERGENCY DEPARTMENT.
I understand and acknowledge that my Tele-visit will establish a therapeutic clinician patient relationship and that my visit information will result in the creation of a medical record of the Tele-visit, if one does not already exist. I acknowledge that I will be asked questions regarding the condition for which I am seeking medical care, and that I am obligated to answer questions truthfully. I agree that I will answer these questions completely and accurately and that, if I cannot understand a question or do not know the answer to a question, I will stop my Tele-visit and schedule an in-person visit. I agree that if I am instructed to discontinue my Tele-visit and contact an available health care provider for any reason, I will do so. I also agree to carefully follow any instructions I receive through my Tele-visit and seek clarification of any instructions that I do not understand. I attest that I am a resident of AND located in the State of New York at the time I start this Tele- visit interview. I attest that I am at least 18 years of age. I acknowledge that Tele-visit is only available to established patients of the neurology practice of Orly Avitzur, MD, PC.
For purposes of the Tele-visit, an "eligible patient" is an individual who is eligible under applicable state laws to be treated using electronic or advanced telecommunications technology. I acknowledge that I have reviewed and agreed to the Tele-visit Terms of Service, and I understand the Tele-visit Privacy Policy. I acknowledge that I am solely responsible for maintaining the safety and security of my login ID and password.
Consent for treatment: I hereby consent to the use of the information I supply as part of the Tele-visit interview by the physician and her non-physician medical secretary. I understand that I will have a chance to discuss and / or refuse the care recommended by my Tele-visit provider. I acknowledge that Tele-visit providers cannot guarantee any specific results or ensure that all of concerns will be resolved during my Tele- visit. I understand that my Tele-visit provider is not able to provide care for all conditions, and I may need to schedule an in-person appointment with a provider. I acknowledge that I am an established patient of the practice of Orly Avitzur, MD, PC, and an "eligible patient" for a Tele-visit. The requirements for an "eligible patient" include having the technology to support the Tele-visit, displaying or having medical conditions (as determined by the physician/specialist) that would allow for appropriate care via an Tele-visit appointment, having established care with the physician/specialist performing the Tele-visit, and maintaining one in-person visit with this medical professional every twelve months.
Electronic health record: I acknowledge that any care provider who uses the electronic record may access and use my health records as needed to provide treatment. If I have questions about or concerns with any part of this consent, I will call the number below to discuss them. The authorizations on this form will remain valid until I revoke (withdraw) them in writing or until the law states they have expired. However, any actions already taken in reliance upon these authorizations will remain valid (I cannot undo actions that were taken while my consent was valid). I may get help with this process at any time by contacting (914) 631-0400. I consent to and authorize Dr. Orly Avitzur to assess my symptoms and health, and recommend treatment if necessary.
I acknowledge that I am a resident of AND am presently located in the State of New York at the time I start this Tele-visit.
I also acknowledge that I have read and agreed to the Informed Consent and Terms of Use.