Access2Health PLLC
Access2Health PLLC
Family Medical Group
Reach us at 1-409-241-7515
Call / Fax us toll free at 1-888-887-0401
Email: support@access2healthpllc.com
1050 S. 11TH St. Beaumont,Texas 77701
        ****Service only available during normal business hours of operation.****

Telemedicine services involve the use of secure interactive video conferencing equipment and
devices that enable health care providers to deliver health care services to patients when located
at different sites.
1. I understand that the purpose of this visit is to assess and attempt to treat my medical condition or
reason for the visit.
2. I understand that telemedicine is done through a two-way video where my healthcare
provider at Access2Health PLLC can see my image on the screen and hear my voice.
However, unlike an in-person consultation, the provider is unable to use senses such as
touch, smell, or use of equipment used in an in-person visit such as a stethoscope or
otoscope, or other forms of equipment for assessment that are equal to that of a face to
face visit.
3. Due to the nature of telemedicine having a provider in a different location than me and
not being face to face, the provider must rely on information provided by me. The
providers at Access2Health PLLC cannot be held responsible for advice,
recommendations, and/or treatment decisions based on inaccurate or incomplete
information provided by me.
4. I understand that I will not physically be in the same location or room as my health care
provider. I will be notified of and my consent will be obtained for anyone other than myself and my healthcare
provider present in the room.
5. I understand that there are potential risks to using technology, including service
interruptions, interception, and technical difficulties.
a. If there is determination that an unresolved issue is present with technology or
telemedicine use, arrangements can be made between the provider and myself for
alternate arrangement to continue the assessment and visit in person.
6. I understand that based on my assessment, my condition may warrant need for further
assessment or diagnostics that are unable to be done by telemedicine and may warrant
further charges that are not included in the consultation fee, 911  notification or my visit to the Emergency room.
7. I understand that this form for consent will become part of my medical record.
8. I understand that this tele-assessment will not be recorded by myself ot others.
9. I certify that this form has been fully explained to me and that I have read it or have had it
read to me. I understand and agree to the contents of this consent for treatment by
telemedicine. I volunteer to participate in the telemedicine examination and authorize
Access2Health PLLC and its healthcare providers to perform assessments and provide
any treatment that may be necessary.
10. I agree to pay the full amount of the telemedicine consult at or before the time of consult.
11. I understand that Access2Health PLLC will not bill insurance and that I will not have a
claim filed towards any health insurance by Access2Health PLLC. I am allowed to ask
for a receipt for visit if I want to file, myself, an insurance claim.



Date:___________________


Time:_____________________ am/pm


Signature:___________________________________________________________


Printed Name:_________________________________________________________


Phone For Telemedicine Consult: ________________________________________
                                                                                              **Phone service charges may apply***


Email_________________________________________________________________


                                                            Submit and preceed to the payment screenS