Telemedicine - UCA Women's Center

Urology Centers of Alabama and the UCA Women’s Center is now offering telemedicine as an option for our patient experiencing urologic issues. Telemedicine consults will be conducted via phone or audio/video communication.

To schedule your telemedicine appointment, please fill out the form below.

Name*
First Last
Patient DOB*
MM slash DD slash YYYY
Patient Email*
Phone*
Physician*
Reason for Visit*
Preferred Appointment Date*
MM slash DD slash YYYY
Important information regarding your telemedicine visit. Please read and click Submit below.
1. NATURE OF TELEMEDICINE CONSULT: During the telemedicine consultation :
  1. Details of your medical history, examinations, x-rays, and test will be discussed with other health professionals through the use of interactive video, audio, and telecommunication technology.
  2. A non-medical technician may be present in the telemedicine studio to aid in the video/audio transmission.
  3. Video, audio and/or photo recordings may be taken of you during the procedure(s) or service(s)
2. MEDICAL INFORMATION & RECORDS: All existing laws regarding your access to medical information and copies of your medical records apply to this telemedicine consultation. Please note, not all telecommunications are recorded and stored. Additionally, dissemination of any patient-identifiable images or information for this telemedicine interaction to researchers or other entities shall not occur without your consent.
3. CONFIDENTIALITY: Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with the telemedicine consultation, and all existing confidentiality protections under federal and Alabama state law apply to information disclosed during this telemedicine consultation.
4. RIGHTS: You may withhold or withdraw consent to the telemedicine consultation at any time without affecting your right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled.
5. RISKS, CONSEQUENCES & BENEFITS: You have been advised of all the potential risks, consequences and benefits of telemedicine. Your health care practitioner has discussed with you the information provided above. You have had the opportunity to ask questions about the information presented on this form and the telemedicine consultation. All your questions have been answered, and you understand the written information provided above. Once your contact form has been submitted, our office will contact you to set up the appointment. Please be aware of the following in regards to telemedicine visits:
  1. A telemedicine visit is not just a phone call, but will be billed to your insurance like any other office visit.
  2. Our office will verify your telemedicine benefits before scheduling. If your insurance requires a copay, we will collect the copay (via credit card) at the time the visit is schedule.
  3. In the event your insurance does not cover telemedicine visits, you will be charged a flat rate visit fee of $50.
Terms and Conditions*
- I accept the Terms & Conditions and have read the above disclaimers. By checking this box, you are consenting to participate in a telemedicine visit. Telemedicine visits (audio, video or both) are billed in the same manner as in-person office visits, and copays for telemedicine visits will be collected up front. In the event your insurance does not cover telemedicine services you will be responsible for paying a flat visit fee of $50.
Electronic Signature*
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