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MassTeleDerm Interface-3c (LIVE)

Welcome to MassTeleDerm E-Visit Registration

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.  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.
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.

 
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