Televero Start My Care Form

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1

Fill out the form

A few minutes, then you're done. This is the same kind of paperwork you'd fill out at any doctor's office before a first visit.

2

Pick your provider and book

If you're 18 or over and live in Texas, Florida, Georgia, Washington, Colorado, or Connecticut, you can pick your provider and book online after you submit the form. Otherwise, our care team will reach out to schedule you with an in-network provider once your form is done.

3

We verify, you visit

After you book, we will reach out to you to verify your insurance and walk you through any costs before your appointment, so there are no surprises. Most plans cover therapy and psychiatry visits, often with little or no out-of-pocket cost. Prefer to pay cash? We have options for that too. Either way, if it's not affordable for you, you can cancel your appointment and never be charged a penny. No questions asked.

Your info is secure. The form is HIPAA-compliant, and your card is processed through a PCI-compliant payment system.

We ask for a credit card near the end of the form to reserve your slot. Every patient adds one. Since we're a 100% online medical practice, we ask here in the form instead of at a front desk. The card isn't charged at all today. You can always change to a different card later if you need to.

Need help filling out the form? Call us at (512) 956-5003.

A heads up before you start: you'll upload photos (front and back) of your insurance card and a photo ID later in the form.

iPhone: you can take the photos when we ask.

Android: take the photos now so you can upload them when we ask.

Are you the patient?*

¿Eres el/la paciente?

Yes

No - I am the patient's parent or guardian

No - I am from a clinic or insurance company assisting the patient

What is your name?*

¿Cómo te llamas?

First Last

Ref Provider Can View PHI?

No

Yes

Are you 18 years old or over?*

Yes

No

¿Tienes más de 18 años?

*Are you over 18 years old?*

What is the patients age?*

¿El paciente es mayor de 18 años?

18 or older

11-17

10 or younger

*What is the patient's age?*

Patient Info Section

Patient Name*

Nombre del paciente

Patient First Patient Last

Is there a different name or nickname the patient would prefer for us to use?*

Yes

No

Preferred Patient Name/Nickname*

Patient date of birth*

Month

Day

Year

Patient Mobile Phone*

Patient Email*

Enter Email Confirm Email

Street Address*

Address Line 2

City*

State*

ZIP Code*

State Text

Patient sex at birth*

Patient gender

Patient race/ethnicity

Parent/Guardian Info

Patient Parent/Guardian Name*

Parent/Guardian First Name Parent/Guardian Last Name

Patient Parent/Guardian Phone*

Patient Parent/Guardian Email*

Patient Parent/Guardian Address

Street Address*

Address Line 2

City*

State*

ZIP Code*

State Text

If a doctor sent you, we can keep them in the loop. If not, just tell us how you found us.

You can type to search the list or scroll. If you came from an ad, those options are at the bottom. Please use them.

I was referred to Televero Health by*

Select the ARC location*

Select the Covenant location*

Select The Children's Clinic location*

Other referring doctor's name*

Name of your Doctor who referred you to us:*

Reason for visit*

Have you been rereferred to us for care related to bariatric surgery?*

Yes

No

We'll verify your insurance before your first appointment, so the more accurate the info here, the smoother things go.

We accept all insurance plans, including Medicare and Medicaid.

If you don't see your plan in the list, just pick "Not Listed" and type in your info. We work with all insurance plans, including ones not shown here.

If you have more than one plan, list what you believe is your main, primary insurance. After you have completed the form, just let us know when we reach out if you have other insurance info and we'll verify that before your first appointment too.

Your coverage details and a few quick photos.

Do you want to submit appointments to insurance or pay out of pocket using your HSA, FSA, cash, or credit card to pay?*

Insurance

No insurance - Out of Pocket (HSA,FSA, Cash, Credit Card)

Coming up: photos of your photo ID, and your insurance card if you have one. Front and back of each. JPG or PNG.

If a photo is too big to upload, take a screenshot of it and upload that instead.

Don't have your cards with you right now?

That's okay. Click Save and Continue Later at the bottom of this page and we'll email you a link so you can finish when you have them.

Upload photos of government issued drivers license/ ID card - Front*

Upload photos of government issued drivers license/ ID card - Back*

Upload photos of insurance card - Front*

Upload photos of insurance card - Back*

Name of your insurance provider*

Name of your insurance provider (Other)*

e.g. Blue Cross Blue Shield, Aetna, United, Tricare, Humana, etc.

Your Insurance Provider Subscriber ID*

You'll find your subscriber ID on your insurance card. Sometimes it's called "Member ID." Type it with no spaces or dashes.

Insurance Policy Effective Date:*

Month

Day

Year

Insurance Policy Holder's Name*

First Last

Insurance Policy Holder's Date of Birth*

Month

Day

Year

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Just in case. We only reach out in a real emergency, and your contact is never notified about your appointments or care.

Emergency Contact Name*

First Last

Relationship to patient*

Emergency Contact Number*

Thanks for being honest. What you shared helps your care team take care of you from your first visit.

You're at the last step. Review the consents, sign, and add a credit card to keep on file.

Medical Records Release Consent*

I consent to allow my referring doctor ("Referring Physician") to release confidential information and a copy of all my medical records, lab tests, or medication history, or a summary or narrative of my protected health information, to U.S. Televero Health, P.A. This information may be used or disclosed in connection with mental health and behavioral health treatment, payment, or healthcare operations.

Authorization for Disclosure of Treatment Information*

I consent to allow my U.S. Televero Health, P.A. Provider ("Televero Health Provider") to release confidential information and a copy of all my treatment history, medical records, lab tests, or medication history, or a summary or narrative of my protected health information, to my Referring Physician This information may be used or disclosed in connection with mental health and behavioral health treatment, payment, or healthcare operations.

Electronic Communications Consent*

I consent to authorize U.S. Televero Health, P.A. to send me marketing and non-marketing electronic communications including appointment information, billing notifications, health education, newsletters, and practice updates via email, text, SMS, and MMS.

Parent or Guardian Consent to Treat a Minor*

I consent to authorize U.S. Televero Health, P.A. to provide mental health treatment and care services via telehealth for the minor patient under the age 18 years old as listed herein. I hereby attest that I am the legal parent or guardian of this minor patient.

ADHD and Stimulant Medication Prescribing Policy*

I attest that I have reviewed and consent to the U.S. Televero Health, P.A. ADHD and Stimulant Medication Prescribing Policy located online at the following link: ADHD and Stimulant Medication Prescribing Policy

Benzodiazepine and Sleeping Medication Prescribing Policy*

I have reviewed and consent to the U.S. Televero Health, P.A. Benzodiazepine and Sleeping Medication Prescribing Policy located online at the following link: Benzodiazepine and Sleeping Medication Prescribing Policy

Additional Consents*

I attest that I have read in full, understand and consent to the following additional attached terms and conditions herein and located on our website at the following links below and also for download at:
https://televerohealth.com/go/tc522
Telemedicine Informed Consent Form
Website Terms and Conditions of Use
Credit/Debit Card Charge Consent
Appointment Agreement and Promise to Pay
Notice of Privacy Practices
Website Privacy Policy
Parent or Guardian Consent to Treat a Minor
ADHD and Stimulant Medication Prescribing Policy
Benzodiazepine and Sleeping Medication Prescribing Policy

Revocation to Consents*

I understand, agree to, and consent that I have a right to revoke any and all consents and/or authorizations herein ("Consent Revication"), in writing, at any time by sending written notification to the authorized entity U.S. Televero Health, P.A. 6101 West Courtyard Drive, Ste. 2-225 Austin, TX 78730 ("Authorized Entity"). I further understand that a revocation of the authorization is not effective to the extent that action has been taken in reliance on the authorization.

Patient Consent: My signature below represents that I acknowledge and consent to the terms and conditions herein. I understand that I will receive a copy of this form and all associated terms and conditions upon completion.

Patient/Parent/Guardian Signature*

Add a credit card to reserve your appointment slot. Every patient adds one. Since we're a 100% online medical practice, we ask here instead of at a front desk. The card isn't charged at all today.

Your card is processed through a secure PCI-compliant payment system. The form is HIPAA-compliant.

After you book, we verify your insurance and walk you through any costs. If it doesn't work for you financially, we cancel your appointment and never charge a penny. No questions asked.

Credit Card*

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

Encrypted Card Details

Credit Card Zip Code*

ZIP Code

Authorize CC on File*

I authorize US Televero Health PA to save my credit card on file. I understand that my credit card will not be charged today with this form submission and my credit card information will be saved on file to be used for any future transactions on my account.

I authorize U.S. Televero Health, P.A. to place my credit card on file. I understand that my credit card information will be saved to file for future transactions on my account.

Almost done. Here's what happens after you hit Submit.

If you're 18 or over and live in Texas, Florida, Georgia, Washington, Colorado, or Connecticut, you'll go straight to our scheduling page. You can book your first appointment with a provider who's in-network with your insurance.

Don't see a time that works? No problem. We'll reach out within a few hours during business hours to get you scheduled.

If you're under 18, or live outside those states, we'll reach out to schedule with the right provider for you.

Prefer not to use the scheduler? That's fine too. We'll text you, or you can call us at (512) 956-5003.

Start My Care Form

Fill out the form

Pick your provider and book

We verify, you visit

Patient Info Section

Parent/Guardian Info

Patient Parent/Guardian Address

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Work and Social Functioning Questions

OCD Questions