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Patient Forms

Consent To Treat Form

Thank you for allowing House Call MD’s to be part of your loved one’s care. We are mobile wound care specialists who provide wound care and dermatology services to clients in nursing homes, assisted living facilities and private homes. We make every effort to provide excellent, state of the art care to any resident in need. Most of our clientele are elderly and have difficulty leaving where they reside. We help your loved ones stay in the comfort of their homes while they are being treated.

We provide weekly visits to our patients and work alongside home health, families, caregivers, nurses and facilities. Our board-certified wound care specialists may do several procedures over the course of wound healing and as part of skin care. These procedures are necessary in order to help your loved ones heal, to help diagnose, treat, decrease infection, or to decrease their risk of skin cancer. These may include debridement, cryotherapy, biopsy, cauterization, toenail debridement, removal of skin tags, removal of suspicious skin conditions, Incision and drainage of abscess, foreign body removal, skin scrapings, suturing, callus shave…just to name a few. Don’t worry, your loved ones are anesthetized with a numbing spray, gel, or injectable to minimize pain and made comfortable. These procedures are all important to skin and wound care because it provides good tissue for healing and valuable information regarding skin and wound progress.

We accept Medicare part B and all PPO’s. We do not accept any HMO’s or Managed Care for payment. Medicare patients are responsible for the yearly deductible which begins each calendar year and for the 20% copay that Medicare does not cover. In most cases, our office will bill the secondary insurance. For those who elect not to carry a secondary insurance, a bill will be sent. At times Medicare’s explanation of our services can be confusing. Our staff will be happy to discuss any question you have about a bill received or any concerns. The attached consent form is being sent for your signature. Please follow the instructions to complete it and thank you for returning it in a timely manner. We look forward to performing excellent, unmatched care for your loved ones and will do our best to help them heal and have favorable skin. 

Telemedicine Consent

Thank you for allowing House Call M.D.’s to be part of your loved one’s care. We are mobile wound care specialists and telemedicine providers who provide wound care, dermatology and now we are offering primary care services to clients in nursing homes, assisted living facilities and private homes. We make every effort to provide excellent, state of the art care to any resident in need. Most of our clientele are elderly and have difficulty leaving where they reside. We help your loved ones stay in the comfort of their homes while they are being treated. We provide weekly visits to our patients and work alongside home health, families, caregivers, nurses and the facilities.

PURPOSE: The purpose of this form is to obtain consent to participate in a telemedicine consultation.

NATURE OF TELEMEDICINE CONSULT: During the telemedicine consultation:

a. Details of your medical history, examinations, x-rays, and tests will be discussed with other health

professionals using interactive video, audio, and telecommunication technology.

b. A physical examination of you may take place.

c. Video, audio, and/or photo recordings may be taken of you during the procedure(s) or service(s).

MEDICAL INFORMATION & RECORDS: All existing laws regarding your access to medical information and copies of your medical records apply to this telemedicine consultation. Please note, not all telecommunications are recorded and stored. Additionally, dissemination of any patient-identifiable images or information for this telemedicine interaction to researchers or other entities shall not occur without your consent.

MEDICAL INFORMATION & RECORDS: All existing laws regarding your access to medical information and copies of your medical records apply to this telemedicine consultation. Please note, not all telecommunications are recorded and stored. Additionally, dissemination of any patient-identifiable images or information for this telemedicine interaction to researchers or other entities shall not occur without your consent.

CONFIDENTIALITY: Reasonable and appropriate efforts have been made to eliminate any confidentiality risk associated with the telemedicine consultation, and all existing confidentiality protections under federal and Florida state law apply to information disclosed during this telemedicine consultation.

RIGHTS: You may withhold or withdraw consent to the telemedicine consultation at any time without affecting your right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled.

DISPUTES: You agree that any dispute arriving from the telemedicine consult will be resolved in Florida, and that Florida law shall apply to all disputes.

RISKS, CONSEQUENCES, & BENEFITS: You have been advised of all the potential risks, consequences, and benefits of telemedicine. Your health care practitioner has discussed with you the information provided above. You have had the opportunity to ask questions about the information presented on this form and the telemedicine consultation. All your questions have been answered, and you understand the written information provided above. 

We accept Medicare part B and all PPO’s. We do not accept any HMO’s or Managed Care for payment. Medicare patients are responsible for the yearly deductible which begins each calendar year and for the 20% copay that Medicare does not cover. In most cases, our office will bill the secondary insurance. For those who elect not to carry a secondary insurance, a bill will be sent. At times Medicare’s explanation of our services can be confusing. Our staff will be happy to discuss any question you have about a bill received or any concerns.

We look forward to providing excellent, unmatched care for you or your loved ones. I agree to participate in telemedicine consultations.