Chesterfield Ophthalmology - Patient Consent for Telemedicine Services
Due to the inability of being seen in the office due to COVID-19 restrictions and precautions, I give my
consent to discuss my medical condition, be evaluated, and receive medical treatment by
telecommunication methods. I understand that the evaluation is not equivalent to an in-person
encounter, but serves as the best medical management of my condition that can be provided using
remote telephone and visual images as indicated.
Additionally, I agree that any telemedicine services rendered by Stephen Busch, D.O. may be billed to
my insurance carrier for appropriate reimbursement.
______________________________________________ ___ / ___ / ________
Patient Name Date of Birth
______________________________________________ ___ / ___ / 2020
Patient (or Legal Guardian/Guarantor) Signature Date
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