""
1

You are scheduled to have a telehealth consultation.

This service will be bulk billed,using the following new Medicare item numbers:


For Consult less than 20 minutes                             For Consult 20 – 40 minutes

 Item Number: 91800                                                   Item Number: 91801

 Benefit Amount: $38.20                                              Benefit amount: $73.95

Agreement

If you (the patient) agree to the assignment of the Medicare benefit directly to the Doctor (bulk bill), please agree to the below.

Doctorplease select the Dr. with whom your TeleHealth consult is booked
I agree to the assignment of the Medicare benefit directly to the provider
Patient Nameyour full name
DOByour date of birth
Date of scheduled consult
Medicare Number
Previous
Next