At HELIUM MEDICAL, we carefully schedule appointments to ensure each patient receives the appropriate amount of time with our physicians and staff. To help us serve you and others effectively, please make every effort to keep your scheduled appointment and arrive on time.

As a courtesy, we will remind you of your upcoming appointment with a phone call 2-5 days in advance and a text message 1 day prior to your scheduled time. If you are unable to keep your appointment, please contact us as soon as possible to reschedule and allow us to accommodate other patients waiting for an appointment.

To ensure fairness to all patients, we ask that you provide at least 24 hours’ notice if you need to cancel or reschedule your appointment.

Failure to cancel or reschedule at least 24 hours in advance may result in a $25.00 “no-show” fee applied to your account. This fee is not covered by insurance and must be paid before ANY future services can be provided. You will receive a direct bill for this charge.

I acknowledge and agree to the “no-show” policy of HELIUM MEDICAL and understand that a charge of $25.00 will apply for missed appointments without prior notice. I also understand that I must cancel or reschedule at least 24 hours in advance to avoid this fee.

Please note: If you miss three consecutive appointments, we may choose to terminate our relationship with you as a patient.

1. I understand that the same standard of care applies to a telemedicine visit as it does to an in-person visit.

2. I understand that during a telemedicine visit, I will not be physically present in the same room as my healthcare provider. I will be informed if anyone other than my healthcare provider is present in the room, and my consent will be obtained for their participation.

3. I acknowledge that there are potential risks associated with using technology, such as service interruptions, technical difficulties, or security breaches.

a. If it is determined that the videoconferencing equipment or connection is inadequate, I understand that either I or my healthcare provider may discontinue the telemedicine visit and make alternative arrangements to continue my care.

4. I understand that I have the right to refuse or stop participating in a telemedicine visit at any time. My decision will be documented in my medical record, and I understand that this will not affect my future care or treatment.

a. I may revoke my consent to participate in telemedicine visits at any time by contacting Helium Medical at 346-762-8822.

5. I understand that the same laws protecting the privacy and confidentiality of my healthcare information apply to telemedicine services.

6. I understand that my healthcare information may be shared with others for scheduling and billing purposes.

a. I acknowledge that my insurance provider may access my medical records for quality review or audit purposes.

b. I understand that I will be responsible for any out-of-pocket costs, such as copayments or coinsurance, associated with my telemedicine visit.

c. I understand that insurance policies for telemedicine visits may differ from those for in-person visits.

7. I understand that this consent form will become part of my medical record.

By signing this form, I confirm that: (1) I have read or had this form explained to me, and fully understand and agree to its contents; (2) I have had all my questions answered to my satisfaction, and the risks, benefits, and alternatives to telemedicine have been explained in a language I understand; and (3) I am located in the state of Texas and will be in Texas during my telemedicine visit(s).