Chicago Dizziness and Hearing Telehealth Consent Form
This form is used in no way other than its stated purpose which is to collect consent for a telehealth visit and billing purposes. A copy of this form can be mailed or e-mailed upon request. Please call (312) 274-0197 with any questions.
Informed Consent for Telephone Consultation
Prior to starting video-conferencing services, we discussed and agreed to the following:

• There are potential benefits and risks of telephone consultations (e.g. limits to patient confidentiality) that differ from in-person sessions.
• Confidentiality still applies for our services, and nobody will record the session without the permission of the other person.
• It is important to be in a quiet, private space that is free of distractions (including cell phone or other devices) during the session.
• It is important to be on time. If you need to cancel or change your tele-appointment, you must notify our office in advance by phone or email.
We will bill insurance on your behalf. Once the claim is adjudicated, we will send you a statement with the balance due to you (if there is any).
Medicare patients: Please make sure you have a smart phone and/or computer with video capabilities. If you or a family member willing to help do not have video capabilities, we are more than happy to reschedule your appointment.
Patient Name *
Date of Birth *
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Phone number to be reached at: *
Electronic Patient Signature Disclosure
By putting your name below, you agree your electronic signature is the legal equivalent of your manual/handwritten signature on this Agreement. You further agree that your signature on this document (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature, and that the lack of such verification will not in any way affect the enforceability of your E-Signature on this agreement between you and Chicago Dizziness and Hearing.
E-Signature *
Appointment Date *
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DD
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YYYY
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