You have chosen to bill your Telemedicine Service to your insurance. By signing this form, you acknowledge that Dr. Sasha Noe and/or Apollo Beach Family Medical Center will file a claim for this service on your behalf to your health insurance plan.

TELEMEDICINE SCREENING CONSENT:

I have requested that Dr. Sasha provide a screening assessment for me regarding the condition agreed upon in my intake.

Via this screen, Dr. Sasha will provide me with feedback for my chief complaint. I acknowledge that this is not a Physician-Patient relationship or agreement. Neither Dr. Sasha nor any of her affiliates, physicians or employees shall have any liability or responsibility for the accuracy and completeness of the information that I provide to them.

By providing a screen assessment only and not as my Medical Doctor under this platform, Dr. Sasha does not assume any responsibility for my medical care or treatment.

For myself and my heirs, personal representatives, administrators, successors and assigns, I irrevocably release Dr. Sasha and its insurers, officers, directors, physicians, employees and affiliates from any and all known or unknown, foreseen and unforeseen, claims, actions, losses or damages arising in connection with this coaching program.

If you have questions regarding the cost related to this service, please contact our Office Coordinator at [email protected]

NOTE: Please do not use our contact information or form for medical emergencies, but rather call 911.

Terms and conditions:

This form is only intended for the request of a telemedicine appointment with our office. We are not able to provide any medical advice through this form.

Once our staff receives the request, it will be processed and you will receive a call to confirm your appointment with our office.