Telemedicine Informed Consent

    1. Purpose: The purpose of this form is to obtain our consent to participate in a telemedicine consultation in connection with your care. You will be asked to consent for each telemedicine consultation.
      • Details of your medical history, examination, x-rays, and tests will be discussed with other health professionals through the use of interactive video, audio, and telecommunication technology.
      • A physical examination of you may take place.
      • A non-medical technician may be present in the telemedicine studio to aid in the video transmission or in the documentation of the visit.
      • Video, audio and/or photo records may be taken of you during the service(s).
    2. Medical Information and Records: All existing laws regarding your access to medical information and copies of your medical records apply to this telemedicine consultation. Please note, not all telecommunications are recorded and stored. Additionally, dissemination of any patient-identifiable images or information for this telemedicine interaction to researchers or other entities shall not occur without your consent. I also authorize the physician to release any information required to process claims or required in the course of my exam.
    3. Confidentiality: Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with the telemedicine consultation, and all existing confidentiality protections under Federal and Arizona state law apply to information disclosed during this telemedicine consultation.
    4. Rights: You may withhold or withdraw consent to the telemedicine consultation at any time without affecting your right to future care or treatment, or risking the loss or withdrawal of any program benefits to which you would be entitled.
    5. Disputes: You agree that any dispute arriving from the telemedicine consult will be resolved in Arizona and that Arizona law shall apply to all disputes.
    6. Costs: I hereby assign my insurance benefits to be paid directly to the physician; or, if my current policy prohibits direct payment to the doctor, I instruct and direct my insurance company to make out the check to me and Arizona Allergy Associates. I understand I will be financially responsible for any copayment, deductible or co-insurance amounts my insurance indicates.
    7. Risks, Consequences, and Benefits: You have been advised of all the potential risks, consequences, and benefits of telemedicine. Your health care practitioner has discussed with you the information provided above. You have had the opportunity to ask questions about the information presented on this form and telemedicine consultation. All your questions have been answered and you understand the written information provided above. I will abide by the No-Show/ Cancellation: HIPAA and Financial policies previously signed.
  • If signed by someone other than the patient.

  • Type name for signature.
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Dear Arizona Allergy Associates Community,

We want to reassure you that we are taking all precautions to prevent the transmission of viral illnesses, including COVID-19. As always, our exam rooms and instruments will be sanitized between each visit and our waiting rooms will be sanitized regularly throughout the day. We are asking that all persons entering the offices wear face coverings. Additionally, please limit the number of persons presenting to the office; we ask that only one parent attends with a child and that additional siblings remain home.

As an extra precaution, we will not be seeing any sick visits or patients with fever or flu-like symptoms at present. We request that any allergy injection patients and/or patients with upcoming office visits reschedule if they have been in contact with someone with fever or flu-like symptoms.

If you suspect you may have a viral illness such as influenza or COVID-19 you should seek emergency care services or primary care services as we are unable to swab and test for these illnesses.

Finally, for all allergy injections patients: out of an abundance of caution and in order to limit your exposure to any viral vectors, we request that you limit close contact in waiting areas. At this time we will temporarily allow you to sit in your vehicle during your 30-minute wait. You will still be required to come in and have your arm read at 30 minutes or earlier if you are experiencing any reaction during your wait. We may also alter your shot schedule to limit your visits to the clinic temporarily.

Thank you for your understanding during these difficult times. These changes are temporary and we will keep you posted with any changes or additional information.