Danielle Weiss, MD, FACP - Center for Hormonal Health and Well-Being, Encinitas, California (760) 753-3636

Danielle E. Weiss, MD, FACP
Center for Hormonal Health and Well-Being

PO BOX 235841
, Encinitas, CA
760-753-3636 (Endo)
Fax: 760-465-2332

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Patient TeleHealth Agreement

Center for Hormonal Health and Well-Being is now offering TeleHealth appointments via Doxy.me. Doxy.me is an online webcam service that allows you to see and talk directly with Dr. Weiss through your computer, smartphone, or tablet from any location with internet access anywhere! This appointment is treated like an in person visit. Your appointment time is saved just for you. If you cancel your appointment with less than 48 business hours notice your appointment hold deposit will not be refunded.

How to get started

First, complete the information/disclaimer below. This will give us consent to treat you via TeleHealth.

After the request is received and evaluated, you will receive an email with the Doxy.me secure link. A few minutes prior to your scheduled appointment time, click on the blue hyperlink provided in the email or through this website

The website will prompt you to check-in by typing your first and last names.

Make sure your webcam and microphone are on. The website will prompt you to allow access to the webcam and microphone, select "Yes."

You will be placed in our virtual waiting room. Stay by your computer until your provider begins your TeleHealth appointment.

You must complete all items for the form to submit.

First Name
Last Name
Phone
() -
Email

Question, Comments, and Procedure Interested in
Please schedule me for a Telehealth appointment

Advance Beneficiary Notice of Noncoverage (ABN)

NOTE: If Medicare or your commercial insurance payer doesn't pay for items listed in table D. below, you may have to pay.

D.	E. Reason Insurance May Not Pay:	F. Estimated Cost
New patient (telehealth and/or in person) appointment	Not a covered benefit	$212.70
Follow-up patient (telehealth and/or in person) appointment	Not a covered benefit	$142.76
Appointment hold deposits (will be refunded if cancelations or changes are made with more than 48 business hour notice)	Not a covered benefit	New patient appointments $75 Follow-up appointments $25

WHAT YOU NEED TO DO NOW:

Read this notice, so you can make an informed decision about your care.
Ask us any questions that you may have after you finish reading.
Choose an option below about whether to receive the D. TeleHealth service listed above.

G. OPTIONS: Check only one box. We cannot choose a box for you.

OPTION 1. I want the D. TeleHealth service listed above. I understand that if Medicare or my commercial insurance doesn't pay, I am responsible for payment, but I can appeal to Medicare or my commercial insurance. If Medicare or the commercial insurance plan does pay, you will refund any payments I made to you, less co-pays or deductibles.

OPTION 2. I want the D. TeleHealth service listed above, but do not bill Medicare or my commercial insurance. You may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare or my commercial insurance is not billed.

OPTION 3. I don't want the D. TeleHealth service listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare or commercial insurance would pay.

H. Additional Information:

E-Signing below means that you have received and understand this notice.

Disclaimer:

I understand that I am registering for a TeleHealth appointment with Dr. Danielle Weiss at Center for Hormonal Health and Well-Being

I understand that TeleHealth technology will be used to connect me with Dr. Danielle Weiss. Telehealth appointments may be conducted by videoconferencing. I understand that this appointment will not be the same as a direct patient/health care provider visit due to the fact that I will not be in the same room as my health care provider. I understand that the health care provider will be unable to complete a physical examination during this visit.

I understand there are potential risks to this technology, including interruptions, unauthorized access and technical difficulties. I understand that my healthcare provider or I can discontinue the TeleHealth appointment if it is felt that the videoconferencing connections are not adequate for the situation. I understand that I can discontinue the TeleHealth appointment at any time.

I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Others may also be present during the appointment other than my healthcare provider to complete documentation and orders. The above-mentioned people will all maintain confidentiality of the information obtained.

I have had the alternatives to a TeleHealth appointment explained to me, and in choosing to participate in a TeleHealth appointment, I understand that some parts of the evaluation such as physical examination or on-site testing will be unavailable.

In an emergency situation, I understand that the responsibility of the TeleHealth specialist or provider may be to direct me to emergency medical services, such as the emergency room.

I understand that billing for the TeleHealth appointment will occur from 1) the primary care provider and 2) TeleHealth provider, and 3) as a facility fee from the site from which I am presented. Billing is at the discretion of the provider. Billing procedures will be explained to me.

I have read this document carefully, and understand the risks and benefits of the TeleHealth appointment and have had my questions regarding the procedure explained and I hereby consent to participate in a TeleHealth appointment visit under the terms described herein.

By filling in your full name below, you agree to this disclaimer:

By hitting the "submit" button below this will be electronically sent to Dr. Weiss's office.