Telehealth consultation consent form

1

You are scheduled to have a telehealth consultation.

This service will be bulk billed,using the following new Medicare item numbers:


For Consult less than 20 minutes                             For Consult 20 – 40 minutes

 Item Number: 91800                                                   Item Number: 91801

 Benefit Amount: $38.20                                              Benefit amount: $73.95

Agreement

If you (the patient) agree to the assignment of the Medicare benefit directly to the Doctor (bulk bill), please agree to the below.

I agree to the assignment of the Medicare benefit directly to the provider
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