Prior to your virtual visit, you will be asked to consent to the following terms and conditions.
Telemedicine Consent to Treat
Your visit will be conducted virtually due to COVID-19 countermeasures. You are giving verbal consent to have your visit conducted by this same means with treatment provided remotely. You verbally consent to the billing and collection practices of the provider's medical group.
Assignment of Insurance Benefits
In consideration of any and all medical services, care, drugs, supplies, equipment, and facilities furnished by SLUCare Physician Group and all attending physicians, I hereby irrevocably assign and transfer to said SLUCare Physician Group and all attending physicians, all insurance benefits now due and payable to me under any insurance policy or policies thereof that might be applicable.
I hereby transfer payment of benefits for medical and/or surgical services rendered by physicians for whom SLUCare Physician Group is authorized to charge and bill.
I understand that my obligation to pay all charges is not affected by the fact that I have insurance benefits, and if my insurance company fails to pay all or any portion of these charges for any reason, I will be responsible for all sums due and owing SLUCare Physician Group.
Guarantee of Account
In consideration of any and all medical services rendered by SLUCare Physician Group in regard to this virtual visit, I agree to pay SLUCare Physician Group the charges for all services ordered by SLUCare providers, patient and patient’s family including any deductibles, coinsurance or amounts not paid by the patient’s insurance plan, including Medicare and Medicaid. If the requirements for referral, second opinion, or pre-certification of care, as outlined by the patient’s insurance carrier, have not been followed, I understand that I will be responsible for all charges incurred.
SLUCare Physician Group and the patient or patient’s representative hereby enter into the above agreement. The patient or patient’s representative certifies that he/she has read and accepted the above, where applicable to the patient’s condition and status, and further certifies that he/she is the patient, or is duly authorized on behalf of the patient, to execute such an agreement.
Notice of Privacy Practices
I acknowledge that I have had the opportunity to review SLUCare Physician Group’s Notice of Privacy Practices.