REGISTRATION & MEDICAL HISTORY FORMS need to be downloaded, completed & returned prior to your consultation. Please provide a copy of your insurance card along with a photo ID.
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Two business days before your appointment, you will receive a reminder call. CONSULTATIONS MUST BE RECONFIRMED.
Please read HIPAA, EMAIL & TeleHealth Consent/Policies below. Acknowledge reading each when filing out the registration form.
If you wish to have a previous provider release information, you may forward the form below to them.
If you wish to have a previous provider release information, you may forward the form below to them.
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RELEASE OF INFORMATION FORM
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HIPAA POLICIES
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EMAIL POLICY & CONSENT: Email confidentiality is not guaranteed. Shared use of computers may result in email accounts being accessed by members of your household or place of employment.
Email is not intended as a substitute for clinical care.
Messages must be concise. Lengthy emails may result in a delayed response by the doctor.
Emails do become a part of your medical record.
Providing your email address gives Dr. Bergman and his assistant permission to use it.
Email is not intended as a substitute for clinical care.
Messages must be concise. Lengthy emails may result in a delayed response by the doctor.
Emails do become a part of your medical record.
Providing your email address gives Dr. Bergman and his assistant permission to use it.
TELEHEALTH CONSENT
I understand that Dr. Ira Bergman will be primarily rendering care services to me via Doxy.me telehealth platform.
Doxy.me provides security protocols to protect confidentiality of patient identification and imaging data. They take active measures to safeguard against any intentional or unintentional corruption of data.
The BENEFIT of telehealth is saving travel time and expense getting to the doctor’s office. It allows for a greater ease of receiving medical care.
The POTENTIAL RISKS include but are not limited to:
-Technical glitches may interfere with video and or sound transmission which may delay medical evaluation and treatment.
-Privacy limitations. Provider cannot control sound which may be overheard at the patients end thus breeching confidentiality.
-If the need for an in person visit or being seen in person by another provider exists, I will cooperate with that recommendation.
I understand the laws that protect privacy also pertain to medical information obtained by telehealth.
I understand that I have the right to withdraw consent to the use of telehealth at any time during the course of treatment. Due to limited in person office hours, that may result in the need to transfer care to a new provider.
In signing the acknowledgement in my registration paperwork, I understand the information provided regarding telehealth. I have had the opportunity to speak with Dr Bergman’s assistant and answer any questions regarding telehealth.
THE LINK FOR VIDEO IS ALWAYS:
doxy.me/irabergmanmd
Please reboot your device BEFORE your appoinment. Use Chrome or Brave browser for most reliable camera & microphone functioning.
I understand that Dr. Ira Bergman will be primarily rendering care services to me via Doxy.me telehealth platform.
Doxy.me provides security protocols to protect confidentiality of patient identification and imaging data. They take active measures to safeguard against any intentional or unintentional corruption of data.
The BENEFIT of telehealth is saving travel time and expense getting to the doctor’s office. It allows for a greater ease of receiving medical care.
The POTENTIAL RISKS include but are not limited to:
-Technical glitches may interfere with video and or sound transmission which may delay medical evaluation and treatment.
-Privacy limitations. Provider cannot control sound which may be overheard at the patients end thus breeching confidentiality.
-If the need for an in person visit or being seen in person by another provider exists, I will cooperate with that recommendation.
I understand the laws that protect privacy also pertain to medical information obtained by telehealth.
I understand that I have the right to withdraw consent to the use of telehealth at any time during the course of treatment. Due to limited in person office hours, that may result in the need to transfer care to a new provider.
In signing the acknowledgement in my registration paperwork, I understand the information provided regarding telehealth. I have had the opportunity to speak with Dr Bergman’s assistant and answer any questions regarding telehealth.
THE LINK FOR VIDEO IS ALWAYS:
doxy.me/irabergmanmd
Please reboot your device BEFORE your appoinment. Use Chrome or Brave browser for most reliable camera & microphone functioning.