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Telehealth Consent
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Telehealth using App
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Originating site:
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Originating site:
• • •
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Distant site:
• • •
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Time Started:
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Time ended:
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Patient Type - Insurance/Cash:
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(Select one. Verify with billing if unsure what to choose.)
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Private Insurances (except United) and Cash
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UnitedHealthcare and UMR
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Medicare, Tricare, Medicaid
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Procedure & Place:
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IBT (Private/Cash) - In-Person
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IBT (Private/Cash) - Telehealth
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IBT (Medicare/Tricare/Medicaid) - In-Person
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IBT (Medicare/Tricare/Medicaid) - Telehealth
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IBT (United/UMR) - In-Person
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IBT (United/UMR) - Telehealth
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Time:
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5-21 minutes
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5-21 minutes
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22-36 minutes
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22-36 minutes
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37-49 minutes
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37-49 minutes
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50-70 minutes
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50-70 minutes
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Group: 30 minutes
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Group: 30 minutes
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Group: 60 minutes
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Group: 60 minutes
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All appointment lengths (individual)
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All appointment lengths (individual)
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All appointment lengths (individual)
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All appointment lengths (individual)
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All appointment lengths (group)
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All appointment lengths (group)
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All appointment lengths (group)
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All appointment lengths (group)
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Diagnosis:
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Choose Primary Diagnosis
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Choose Starting BMI:
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Choose Starting BMI:
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Optional - Secondary Diagnosis:
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Choose Secondary Diagnosis
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Please Complete:
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Direct Supervision:
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