YOUR TELEHEALTH APPOINTMENT
As a service to you, Dr Gordon would like to provide the following estimates of the possible costs you might incur for your telehealth consultation/s. You can discuss these costs with your doctor or doctor’s staff to be sure you understand. You will be liable for any costs not covered by Medicare (out-of-pocket). Please note that this is an estimate only of the fees charged by Dr Alex Gordon.
Possible Item Numbers Claimable:
BULK BILL – If Dr Alex Gordon feels it is appropriate, she may decide to bulk bill the consultation and use one of the above item numbers. This means with patient/your consent, one of the Medicare Benefits (above) will be assigned directly to the provider (Dr Alex Gordon), with NO out-of-pocket cost.
OUT OF POCKET COSTS “GAP PAYMENT” OR FULL PAYMENTS can be made by card over the phone – please call the rooms on 5222 2222 after your Telehealth to make payments and to book your next appointment (if required).
- If you are in a situation of financial hardship, please discuss this with us or your doctor and we will do what we can to help
- If you hold a current (BLUE) Centrelink Pension Card, please provide this information to reception, as this may reduce your out-of-pocket costs and/or attract a discount.
- If you require any further information regarding your appointment or guidance on how to access the Telehealth system, please call our friendly reception staff on the above phone number.
Terms
- Payment of an account in full is required within 14 Days of the appointments.
- The Account Holder accepts full liability for Medicare claims which are rejected.
- Monthly account keeping fees may be imposed on overdue accounts at the prevailing rate.
- In the event of the Account Holder being in default of their obligation to pay and the overdue account is then referred to a debt collection agency, and/or law firm for collection.
- Reference to the Account Holder includes reference to his heirs’ executors and permitted assigns and where there is more than one, shall include reference to each of them jointly and severally.
- The Account Holder accepts liability for payment of all accounts incurred by them for the period until the Account Holder advises in writing to the contrary.
Agreement and Consent:
I agree to the appointment being undertaken by telehealth and have read the information above and understand that there could be out-of-pocket costs. If the telehealth appointment is Bulk Billed, I understand and agree to assign the Medicare Benefit Directly to Dr Alex Gordon. I understand that I am able to phone/email the practice for further information and assistance and request a copy of this information at any time.
I have read the above information and possible fee outcomes and wish to continue with the appointment.