Telemedicine

Urology Centers of Alabama and the UCA Women’s Center is now offering telemedicine as an option for our patient experiencing urologic issues. Telemedicine consults will be conducted via phone or audio/video communication.

What is telehealth?

Telehealth is a way to visit with healthcare providers, such as your doctor or nurse practitioner.
You can talk to your provider from any place, including your home. You don’t go to a clinic or hospital.

How do I use telehealth?

You talk to your provider by phone, computer, or tablet.
Sometimes, you use video so you and your provider can see each other.

How does telehealth help me?

You don’t have to go to a clinic or hospital to see your provider.
You won’t risk getting sick from other people.

Can telehealth be bad for me?

You and your provider won’t be in the same room, so it may feel different than an office visit.
Your provider may make a mistake because they cannot examine you as closely as at an office visit. (We don’t know if mistakes are more common with telehealth visits.)
Your provider may decide you still need an office visit.
Technical problems may interrupt or stop your visit before you are done.

Will my telehealth visit be private?

We will not record visits with your provider.
If people are close to you, they may hear something you did not want them to know. You should be in a private place, so other people cannot hear you.
Your provider will tell you if someone else from their office can hear or see you.
We use telehealth technology that is designed to protect your privacy.
If you use the Internet for telehealth, use a network that is private and secure.
There is a very small chance that someone could use technology to hear or see your telehealth visit.

What if I try telehealth and don’t like it?

You can stop using telehealth any time, even during a telehealth visit.
You can still get an office visit if you no longer want a telehealth visit.
If you decide you do not want to use telehealth again call 205-930-0920 and say you want to schedule an appointment with your provider.

How much does a telehealth visit cost?

What you pay depends on your insurance.
A telehealth visit will not cost any more than an office visit.
If your provider decides you need an office visit in addition to your telehealth visit, you may have to pay for both visits.
In the event your insurance does not cover telemedicine visits, you will be charged a flat rate visit fee of $50.

What does it mean if I consent to a Telehealth visit?

If you consent for a telehealth visit, you agree that:

We talked about the information in this document.
We answered all your questions.
You want a telehealth visit.

Urology Centers of Alabama and the UCA Women’s Center is now offering telemedicine as an option for our patient experiencing urologic issues. Telemedicine consults will be conducted via phone or audio/video communication

To schedule your telemedicine appointment, please fill out the form below.

Important information regarding your telemedicine visit. Please read and click Submit below.

Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Email Address*
Phone #*
Physician*
Reason for Visit*
Preferred Appointment Date*
MM slash DD slash YYYY
Important information regarding your telemedicine visit. Please read and click Submit below.
1. NATURE OF TELEMEDICINE CONSULT: During the telemedicine consultation :
  1. Details of your medical history, examinations, x-rays, and test will be discussed with other health professionals through the use of interactive video, audio, and telecommunication technology.
  2. A non-medical technician may be present in the telemedicine studio to aid in the video/audio transmission.
  3. Video, audio and/or photo recordings may be taken of you during the procedure(s) or service(s)
2. MEDICAL INFORMATION & 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.
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 Alabama 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 otherwise be entitled.
5. RISKS, CONSEQUENCES & 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 the telemedicine consultation. All your questions have been answered, and you understand the written information provided above. Once your contact form has been submitted, our office will contact you to set up the appointment. Please be aware of the following in regards to telemedicine visits:
  1. A telemedicine visit is not just a phone call, but will be billed to your insurance like any other office visit.
  2. Our office will verify your telemedicine benefits before scheduling. If your insurance requires a copay, we will collect the copay (via credit card) at the time the visit is schedule.
  3. In the event your insurance does not cover telemedicine visits, you will be charged a flat rate visit fee of $50.
Terms and Conditions*
- I accept the Terms & Conditions and have read the above disclaimers. By checking this box, you are consenting to participate in a telemedicine visit. Telemedicine visits (audio, video or both) are billed in the same manner as in-person office visits, and copays for telemedicine visits will be collected up front. In the event your insurance does not cover telemedicine services you will be responsible for paying a flat visit fee of $50.
Electronic signature*
Name
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