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Patient Forms

Consent To Treat Form

Thank you for choosing Florida Wound Healing as part of your loved one’s care. We are experts in mobile wound care and dermatology services, offering our specialized assistance to clients residing in private homes, nursing homes, and assisted living facilities. Our priority is to provide top-notch, modern care to every resident requiring it. As mainly elderly clients find it difficult to move out of their residencies, we assist them with treatment while they remain comfortable in the familiarity of their own homes.

At Florida Wound Healing, we offer weekly visits to our patients and collaborate with home health services, family members, caregivers, nurses, and healthcare facilities. Our team of certified specialists in wound care may perform various procedures in the course of healing and skincare to assist in the diagnosis, treatment, infection prevention, and risk reduction of skin cancer for your loved ones. These treatments may involve debridement, cryotherapy, biopsy, cauterization, toenail debridement, tag removal, suspicious lesion removal, abscess incision and drainage, foreign object removal, skin scrapings, suturing, callus shaving, and more. Rest assured, we use numbing spray, gel, or injections to keep your loved ones anesthetized and comfortable during the procedures. These interventions are critical to wound and skin care as they promote optimal tissue healing and yield pertinent data on skin and wound progress.

Florida Wound Healing accepts Medicare part B and all PPO’s. We do not accept any HMO’s or Managed Care as a means of payment. Medicare patients are responsible for the yearly deductible, which begins each calendar year, and for the 20% copay that Medicare does not cover. Our office will typically bill the secondary insurance for most cases. For those who choose not to carry secondary insurance, we will send a bill. Occasionally, Medicare’s explanation of our services can be perplexing. Our staff is available to address any questions you have regarding a received bill or any other concerns. Please find attached the consent form for your signature, which should be completed as instructed and returned in a timely manner. We are committed to providing excellent and unparalleled care for your loved ones, and we will do our best to help them heal and attain healthy skin.

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Telemedicine Consent

Thank you for choosing Florida Wound Healing as a part of your loved one’s care. Our team comprises of mobile wound care specialists and telemedicine providers, offering wound care, dermatology and primary care services to those who require medical attention in nursing homes, private residences, and assisted living facilities. Our team strives to offer the best state-of-the-art care to any resident in need, particularly the elderly who have difficulties with mobility. We prioritize patient comfort, and our services allow patients to receive treatment while remaining in their homes. Our team conducts weekly visits, coordinating with home health, families, caregivers, nurses, and facilities to ensure continuity of care.

PURPOSE: The objective of this document is to acquire permission to engage in a telemedicine examination as part of Florida Wound Healing’s services.

NATURE OF TELEMEDICINE CONSULT: During the telemedicine consultation:

a. Your medical records, physical assessments, radiographs, and evaluations will be analyzed with other healthcare experts by utilizing interactive video, audio, and telecommunications technology

A potential assessment of your physical condition may be conducted.

c. We may capture visual, auditory, and photographic documentation of your procedure(s) or service(s)

MEDICAL INFORMATION & RECORDS: The existing regulations about obtaining medical data and duplicates of your medical files are valid for this virtual medical consultation. Be aware, not all means of communication will be preserved. Furthermore, sharing identifiable patient-related images or information to scholars or other organizations is forbidden without your authorization.

MEDICAL INFORMATION & RECORDS: The rules governing your ability to acquire medical data and duplicates of your medicinal archives persist throughout this remote medical consultation. It’s crucial to bear in mind that recordings of every telecommunication session might not be recorded or retained. Apart from that, your agreement is necessary prior to any disclosure of patient-specific images or information from this telemedicine interaction to researchers or other organizations.

CONFIDENTIALITY: Reasonable and appropriate efforts have been made to eliminate any confidentiality risk associated with the telemedicine consultation, and all existing confidentiality protections under federal and Florida state law apply to information disclosed during this telemedicine consultation.

You have the right to withhold or revoke consent for telemedicine consultations without jeopardizing your eligibility for future medical attention, treatment, or program benefits

DISPUTES: You acknowledge that any conflict arising from the telemedicine consultation will be settled in Florida, with the regulations of Florida being applicable to any disagreements.

RISKS, CONSEQUENCES, & BENEFITS: You have been adequately informed of the potential hazards, outcomes, and advantages of telemedicine. Your healthcare professional has examined the data furnished above with you. You have had the chance to clarify any doubts regarding this form and the telemedicine consultation. Your inquiries have been resolved, and you have comprehended the written information provided herein.

We welcome Medicare part B and every PPO, but we cannot receive any HMO’s or Managed Care compensation. You, as a Medicare patient, are accountable for paying the yearly deductible, which initiates every year, as well as the 20% copay that Medicare does not cover. Our office generally will charge the secondary insurance. However, those who choose to not carry a secondary insurance will receive a bill. On occasion, Medicare may have difficulty explaining our services, and our staff is available to clarify any billing inquiries or worries.

Our commitment is to deliver unparalleled and top-tier healthcare services to you or your beloved ones. I consent to engage in remote medical appointments.