Virtual Consultation Visit Out of State

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Notice of Privacy Practices 

This notice explains how your medical information (PHI) may be used and disclosed, and your rights regarding that information.

How We Use Your Health Information

We may use or share your PHI to:

  • Provide and coordinate your care.
  • Bill you, your insurance, or other payers.
  • Run health care operations, including quality improvement.
  • Comply with laws and regulations.
  • Communicate with family or caregivers (with your consent or when allowed).

We may also use or disclose PHI in special cases such as emergencies, public health reporting, research (with safeguards), law enforcement, organ donation, or when required by law.

We will not sell your PHI or use it for marketing without your written authorization.

Your Rights

You have the right to:

  • Access and copy your records, including electronic copies.
  • Request corrections to information you believe is inaccurate.
  • Receive a list of certain disclosures of your PHI.
  • Request restrictions on how we use or share your PHI.
  • Request confidential communications (e.g., alternate address or phone number).
  • Revoke your authorization for use/disclosure at any time (except when action has already been taken).

Our Responsibilities

We are required to:

  • Protect the privacy of your PHI.
  • Provide you with this Notice.
  • Notify you if a breach of unsecured PHI occurs.
  • Follow the terms of this Notice (and update it if our practices change).

Questions or Complaints

If you have questions or believe your privacy rights have been violated, you can contact:

Houston Concierge Medicine Wellness PLLC
9432 Katy Freeway, Suite #400, Houston, TX 77055
(832) 991-8940

Patient Financial Consent – Self-Pay Telehealth Visit

I understand that [Clinic/Provider Name] is out of network with local insurance plans.
I acknowledge and agree that:

  • This visit is being billed on a self-pay basis.
  • My insurance will not be billed for this service.
  • The cost of a telehealth visit is $150, which I am responsible for paying at the time of service.
  • I will not submit this claim to my insurance for reimbursement unless I choose to do so on my own.

By signing below, I confirm that I understand and agree to these terms.

* Country
* State/Province
Sub Total
$150.00
TOTAL
$150.00

Your Form Has Been Submitted

Thank You! Your Form Has Been Submitted.

Thank you for your interest in an out-of-state virtual consultation with Houston Concierge Medicine.

Our team has received your information and will review your request to confirm eligibility and availability based on your location and medical needs.

A member of our team will contact you with next steps and scheduling information.

Questions? We're Here to Help.

Call or text us at 713-333-6464 during regular business hours, Monday through Friday, 9 AM to 5 PM Central Time.

We look forward to connecting with you!

Houston Concierge Medicine

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