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MassTeleDerm Interface-3j (ACTIVE)

Welcome to MassTeleDerm E-Visit Registration

INSTRUCTIONS:  Please complete the questions that follow.   
Please be sure to continue until the end. When you see the message "Thank you!"  you are all set!  If you do not get to this message, then please be aware that your responses have not yet been submitted and cannot be processed.
1. Have you (the patient) been seen as a patient at our office (Massachusetts Dermatology Associates in Beverly, MA) over the past 3 years? *This question is required.
2. Have you (the patient) ever completed a virtual telemedicine visit with our office?  *This question is required.
INFORMED CONSENT FOR TELEMEDICINE SERVICES AT MASSDERM

Telemedicine at MassDerm involves the use of secure (HIPAA compliant) electronic communications to enable patient care "at a distance" with the objective of improving access to patient care.

Telemedicine appointments (virtual visits) will focus on one medical concern.   If you have multiple concerns, we recommend you consider scheduling an in-person appointment or scheduling additional virtual visits.

There is a per virtual visit $80 deposit for patients who do not participate in Medicare Part B (excludes Medicare Advantage patients who need to pay deposit) or MassHealth that will be collected by phone after you complete this online registration.   After your visit is complete and your insurance has reimbursed MassDerm, your deposit (minus any owed copay, co-insurance, or deducible) will be refunded to your credit card.  If your insurance fails to reimburse for the visit, your $80 will not be refunded ($80 would be your maximum out-of-pocket cost for this single virtual visit).  It may take 4-8 weeks for insurance processing.  Note that if you have commercial medical insurance (i.e. non-Medicare Part B or MassHealth) and there are technical difficulties with video at the time of your visit, if you continue with a phone (audio, non-video) encounter with your provider, you will be charged $80 out-of-pocket for that encounter.  Additionally, If you do not have medical insurance or your medical insurance is not accepted by MassDerm, you have the option to pay $80 out-of-pocket per telemedicine visit. 

Photographs that you provide of skin lesions, rashes, and certain other medical concerns during this registration may be examined by your designated dermatology provider BEFORE your virtual visit.  If your provider deems that your medical concern is not appropriate for evaluation and management via telemedicine, your deposit will be refunded and you will have the option to schedule an in-person visit.

While every effort is made to maximize benefit and minimize harm, as with any medical procedure, there are risks.  In the case of telemedicine, possible risks include misdiagnosis (due to the inferiority of a virtual physical exam compared to an in-person exam) and technology failure during the evaluation leading to a sub-optimal physician-patient interaction.  While every effort is made to safeguard your personal information, there is the rare risk of data breach with one of our HIPAA-compliant service partners.  The laws that protect privacy and the confidentiality of medical information also apply to telehealth. As always, your insurance carrier will have access to your medical records for quality review/audit.

You have the right to seek care elsewhere and/or withdraw your consent to the use of telehealth in the course of your care at any time, without affecting your right to future care or treatment at MassDerm.  You may revoke your consent orally or in writing.  As long as this consent is in force (has not been revoked), all dermatology providers at Massachusetts Dermatology Associates may provide healthcare services to you via telehealth without the need for another consent form.

By choosing YES, I (the patient or patient's guardian) acknowledge that I have read and understand the information provided above, and I hereby give my informed consent for the use of telemedicine in my medical care at Massachusetts Dermatology Associates. *This question is required.
SUPPLEMENTAL TERMS FOR SERVICES AT MASSDERM

While we hope that we can address your concern through this virtual visit, if you do end up visiting us at our office in Beverly, MA, please acknowledge the following terms:  
  1. I have been provided access to "Notice of Privacy Practices" which can be found here.
  2. Photographs uploaded by me to this online platform as well as photographs taken by providers at MassDerm may be incorporated into my medical record.
  3. Staff from MassDerm may call and leave voicemail on my provided phone number(s) and send emails to my provided email address for appointment reminders, billing items and other issues pertaining to my care.  I also authorize MassDerm to share my medical information with other providers involved in my care.
  4. If I am unable to keep an appointment, I will provide a minimum of 24 hour notice.  This courtesy on my part will make it possible to give my appointment to another patient who needs it.  In the event that I am unable to give such notice, I may incur a no-show fee.
  5. Outside pathology, lab fees:  Biopsy, pathology and lab samples taken at the office and sent outside of our office for processing are billed independently of Massachusetts Dermatology Associates.  If I undergo such procedures, I may receive a bill from the outside lab and will be responsible for payment to that facility.
  6. I understand that while Massachusetts Dermatology Associates physicians contract with several insurance companies, it is my responsibility to verify with my plan that the physician I am seeing is a participating provider.  It is also my responsibility to verify the extent of my insurance coverage for various services offered at the practice.  I further understand that it is my responsibility to obtain necessary referrals and/or authorizations required by my insurance company.  If authorization is not obtained I may be financially responsible for services rendered.   I acknowledge responsibility for all charges that my insurance does not cover.  I also hereby assign and authorize payment of medical benefits. Payments may be made on my behalf directly to Massachusetts Dermatology Associates, P.C. for services rendered.  I also authorize Massachusetts Dermatology Associates, P.C. to release necessary medical information to my insurance company, its agents, or any third party in order to determine payable benefits for the services rendered.

By choosing YES, I (the patient or patient's guardian) acknowledge that I have read and understand the information provided above, and I agree and hereby give my informed consent for treatment at Massachusetts Dermatology Associates, for both virtual and in-office visits. *This question is required.
KEY SYSTEM NAVIGATION TIPS

1.  If possible, we recommend you proceed with a smart phone (iPhone or Android) if you would like to include photos of your medical concern with your visit registration (using your phone's camera app).  If you prefer to use a computer and would like to include photos, you can upload the photos to this system.

2.  ALL USERS: If you have technical difficulties with this system, please call 978-225-3376 during regular business hours and ask for a member of our telederm team.

3.  SMART PHONE USERS (iPhone or Android):  After answering all questions on each page, you must click the arrow on the bottom right side of your screen to proceed to the next set of questions. The arrow is a white forward facing triangle within a blue square.