WE ARE OFFERING TELEMEDICINE SERVICES FOR CONSULTATION DURING COVID-19 PANDEMIC. YOU CAN USE YOUR COMPUTER, LAPTOP, IPAD, PHONE OR SMART DEVICES TO CONNECT WITH US. WE WILL SUBMIT THE CONSULTATION TO YOUR INSURANCE FOR REIMBURSEMENT. IF YOUR INSURANCE DOES NOT COVER TELEMEDICINE, A FEE OF $90 WILL APPLY FOR EXISTING PATIENTS, $110 FOR NEW PATIENTS. THANK YOU FOR YOUR UNDERSTANDING.
CALL OUR OFFICE AT (281) 557-0707, E-MAIL OR QR TEXT US TO SET UP AN APPOINTMENT (SEE CONTACT US PAGE).
PLEASE READ THE TELEMEDICINE CONSENT FORM.
WE WILL EMAIL OR TEXT YOU A LINK DURING YOUR APPOINTMENT TIME. USE CHROME, FIREFOX OR SAFARI BROWSER ON YOUR DEVICE, AND MAKE SURE YOUR AUDIO AND VIDEO ARE TURNED ON. DESKTOP COMPUTERS MUST HAVE A CAMERA AND MICROPHONE.
PLEASE READ THE TELEMEDICINE CONSENT FORM. DOWNLOAD PDF, SIGN AND UPLOAD FORM VIA PATIENT PORTAL. YOU MAY ALSO GIVE A VERBAL CONSENT.
I. Introduction. Telemedicine involves the real-time evaluation, diagnosis, consultation on, and treatment of a health condition using advanced telecommunications technology, which may include the use of interactive audio, video, or other electronic media. As such, telemedicine allows the provider to see and communicate with the patient in real-time.
II. Consent for Treatment. I voluntarily request Amir Salim MDPA physician(s) and such associates, technical assistants and other health care providers as they may deem necessary to participate in my medical care through the use of telemedicine. I understand that Amir Salim MDPA Telemedicine Providers (i) may practice in a different location than where I present for medical care, (ii) may not have the opportunity to perform an in-person physical examination, and (iii) rely on information provided by me. I acknowledge that Amir Salim MDPA Telemedicine Providers’ advice, recommendations, and/or decision may be based on factors not within their control, such as incomplete or innacurate data provided by me or distortions of diagnostic images or specimens that may result from electronic transmissions. I acknowledge that it is my responsibility to provide information about my medical history, condition and care that is complete and accurate to the best of my ability. I understand that the practice of medicine is not an exact science and that no warranties or guarantees are made to me as to result or cure. If Amir Salim MDPA Telemedicine Providers determine that the telemedicine services do not adequately address my medical needs, they may require an in-person medical evaluation. In the event the telemedicine session is interrupted due to a technological problem or equipment failure, alternative means of communication may be implemented or an in-person medical evaluation may be necessary. If I experience an urgent matter, such as a bad reaction to any treatment after a telemedicine session, I should alert my treating physician and, in the case of emergencies dial 911, or go to the nearest hospital emergency department.
III. Release of Information. To facilitate the provision of care and/or treatment through telemedicine, I voluntarily request and authorize the disclosure of all and any part of my medical record (including oral information) to Amir Salim MDPA Telemedicine Providers. I understand and agree that the information I am authorizing to be released may include: 1) AIDS/HIV test results, diagnosis, treatment, and related information: 2) drug screen results and information about drug and alcohol use and treatment; 3) mental health information; and 4) genetic information. I understand that the disclosure of my medical information to Amir Salim MDPA Telemedicine Providers, including the audio and/or video, will be by electronic transmission. Although precautions are taken to protect the confidentiality of this information by preventing unauthorized review, I understand that electronic transmission of data, video images, and audio is new and developing technology and that confidentiality may be compromised by failures of security safeguards or illegal and improper tampering. I certify that this form has been fully explained to me, that I have read it or have had it read to me, and that I understand its contents.
Patient Complaint Procedure
While we hope every patient’s visit goes smoothly, it is important that we are notified of patient concerns so we can take the appropriate steps to address them. A patient has the right to communicate a verbal or written complaint or concern regarding any aspect of his/her visit (i.e. medical care, service, conditions, billing) and expect a timely response. If you have comments, questions, or concerns, we recommend that you or your representative: • Discuss them with your immediate caregiver, or • Speak to the manager of the clinic or service in which you are receiving care, or • If you believe your questions or concerns have not been adequately addressed, you may request a review by contacting Amir Salim MDPA at 281-557-0707 or in writing at the address below: AMIR SALIM MDPA 450 N. Texas Ave. Ste C Webster, TX 77598
Notice regarding complaints about physicians, as well as other licensees and registrants of Texas medical Board, including physician assistants, acupuncturists, and surgical assistants may be reported for investigation at the following address: Texas Medical Board Attention: Investigations 333 Guadalupe, Tower 3, Suite 610 P.O. Box 2018, MC-263 Austin, TX 78768-2018 Assistance in filing a complaint is available by calling the following telephone number: 1-800-201-9353. For more information please visit the Texas medical Board website at www.tmb.state.tx.us If you are with a health maintenance organization and wish to file a complaint, you may do so by contacting the Texas Department of Insurance at 1-800-252-3439.