The Virtual TeleConsult Clinic:

The Virtual TeleConsult Clinic: Leveraging Cost-Effective Technology to Improve Access to Quality Tertiary Health Care www.musc.edu/vtcc Patient Packet VTCC is funded by a grant from the Duke Endowment to establish a telemedicine program to support providers in underserved communities in SC. Samir Fakhry, MD, Principal Investigator 843-792-9722 Fakhry@musc.edu Laura Langston, Program Coordinator 843-792-7040 langstl@musc.edu Medical University of South Carolina 96 Jonathan Lucas Street CSB 426 MSC 613 Charleston, SC 29425 Fax: 843-792-1892

TeleConsult Documents This form is for completion by the referring physician to schedule a teleconsult appointment for a patient. 1) VTCC Referral Form Following completion of this document, please return via fax or email as an attachment to: Laura Langston Program Coordinator langstl@musc.edu Fax: 843-792-1891 Office: 843-792-7040

MUSC s VTCC TELEMEDICINE PROGRAM REFERRAL FORM The Referring Physician/staff should complete this form for scheduling a TeleConsult with an MUSC specialist. Please clearly print or type. Please return completed form via fax or email as an attachment to: Laura Langston Program Coordinator langstl@musc.edu Fax: 843-792-1891 Office: 843-792-7040 TeleConsult Schedule Do not write in this box. MUSC scheduler to complete. Day Date Time Clinical Information New Follow Up Appointment Appointment Consult Requested: Referring Physician: Phone: Email: Presenting Problem: Fax: MUSC Specialist Notes: Physician Signature & Date: Patient Information Patient s Name: Male Female Date of Birth: Social Security #: Primary Phone: Alternate Phone: Street Address City, State, Zip Primary Care Physician: Guarantor Name: ***If patient is 17 years old or younger, Guarantor information required*** (if different than above) Street Address City, State, Zip Male Female Date of Birth: Social Security #: Relationship to patient: Insurance Information Name of Insured: Insured Date of Birth: Primary Insurance: ***Please copy the front and back of the insurance card and attach to this form*** ID# Group # Secondary Insurance: ID# Group # Relationship to patient: MUSC s VTCC is funded by a grant from The Duke Endowment to establish a telemedicine program to support providers in rural underserved communities in SC

TeleConsult Documents These forms are for completion by the patient upon arrival for the teleconsult appointment. 1) Patient Registration 2) MUSC Health Consent for Medical Treatment (front and back) 3) VTCC Patient Pre Participation Survey 4) Medicare ABN Form (if applicable) This form is for completion by the patient following the conducting of the teleconsult appointment. 5) VTCC Patient Post Participation Survey Following completion of these documents, please return via fax or email as an attachment to: Laura Langston Program Coordinator langstl@musc.edu Fax: 843-792-1891 Office: 843-792-7040

VTCC TELEMEDICINE PROGRAM PATIENT REGISTRATION Patient s Name: Appointment Date: Appointment Time: Male Female Date of Birth: Primary Phone: Alternate Phone: Street Address City, State, Zip Referring Physician: Referring Practice: The Telemedicine Process The patient is seen at a VTCC participating local community physician s office and the need for specialist consultation is identified. The community physician refers the patient to the MUSC VTCC coordinator for an appointment with an MUSC specialist. Appropriate records, laboratory and radiologic data are forwarded to the VTCC clinic ahead of the appointment and shared with the consulting MUSC specialist. At the time of the appointment, the patient returns to their community physician s office and a telemedicine link is established between that office and the MUSC specialist for the TeleConsult. The patient completes a consent form and other necessary documents which are forwarded to the MUSC VTCC coordinator. The TeleConsult is conducted via the established platform. The referring community physician or a member of her/his staff would be present to facilitate the process. After completing the VTCC consultation, the MUSC specialist provides a written consultation for the MUSC medical record with copies to the referring physician. Follow-up visits are arranged for either the VTCC or a traditional clinic as needed. Telemedicine Consent Form I understand that my health care provider wishes me to have a telemedicine consultation with the MUSC. This means that I and/or my health care provider or designee will, through interactive video connection, be able to consult with an MUSC subspecialist about my condition. My health care provider has explained to me how the telemedicine technology will be used to do such a consultation. I understand there are potential risks with this technology: 1. The video connection may stop working during the consultation. 2. The video picture or information transmitted may not be clear enough to be useful for the consultation. 3. I may be asked to go to the location of the consulting physician if it is determined that the information obtained via telemedicine was not sufficient to make a diagnosis. The benefits of a telemedicine consultation are: 1. You may not need to travel to the consult location. 2. You have access to a specialist through this consultation. I give my consent to be interviewed by the consulting health care provider. I also understand that other individuals may be present to operate the video equipment and that they will take reasonable steps to maintain confidentiality of the information obtained. I understand that a limited physical examination will take place during the video-conference and that I have the right to ask my health care provider to discontinue the conference at any time. I understand that some parts of the exam may be conducted by individuals at my location at the direction of the consulting health care provider. Any pictures taking during the examination will be maintained as a confidential part of the medical record. The video conference will not be recorded unless I have given written consent to do so. I authorize the release of my relevant medical information to the consulting health care provider, any staff the consulting health care provider supervises, third party payers, and other healthcare providers who may need this information for continuing care purposes. I have read this document and understand the risks and benefits of the telemedicine consultation and have had my questions answered regarding the procedure. I hereby consent to participate in a telemedicine visit under the conditions described in this document. Patient/legal representative signature Relationship Date/time Witness Date/time

Thank you for agreeing to see the MUSC provider today for what we call a virtual clinic visit. Before we begin, we would like to find out what you expect from this experience. And, after you and your local doctor meet with the MUSC provider, we would like you to tell us if what you expected did happen. To tell us, you would fill out or have someone help you fill out two short surveys, one before seeing the MUSC provider and another after taking part in the virtual clinic visit. The MUSC provider will see you whether you volunteer to fill out the surveys or not. Do you agree to fill out the surveys? Yes No Virtual Clinic Visit Patient Pre-Participation Survey First, please tell us about how far you live from MUSC How far have you gone in school? Fewer than 100 miles 100-150 miles 151-200 miles More than 200 miles Less than High School High School Graduate Some College/College Graduate Below are benefits that you may get from taking part in the Virtual Clinic Visit. Mark an X in the box that shows how sure you are that you would receive that benefit. Not at All Somewhat Benefits Sure Sure Give you faster access to care Give you access to care that you do not have in your local area Fill a need in your health care Provide a way for you to receive special care without having to travel long distance Allow your own doctor to give you better quality care Provide a way for you to talk with an expert about your health care needs Reduce your health care costs Set up a way for your own doctor to talk with the MUSC provider about your health care needs Provide a way for the MUSC provider to advise your local doctor about your health care needs Improve your satisfaction with your own doctor Moderately Sure Very Sure Extremely Sure Add to health care options in your doctor s practice What do you want the MUSC provider to know and understand about you before you take part in the virtual clinic visit? What would make you feel that you really benefitted from taking part in the virtual clinic visit? Return to Laura Langston, MUCS VTCC Coordinator. Email: langstl@musc.edu. Fax: 843-792-1891. Address: MUSC-Department of Surgery, 96 Jonathan Lucas Street, MSC 613, Charleston, SC 29425-6130 Survey 1 of 2

Thank you for taking part in tele-consult visit. Because we value what you think, we would like you to fill out this survey to tell us how to make this experience better for you and your local doctor. Please complete the survey below. Virtual Tele-Consult Clinic Patient Post-Participation Survey For each statement below, mark an X in the box that best shows how strongly you agree with the statement. If a statement does not apply to you or you do not know the answer, mark an X in the last box. Statement Use of the Tele-consult equipment My tele-consult visit started on time. I had trouble hearing or seeing the MUSC provider. The MUSC provider had trouble hearing or seeing me. The MUSC provider was able to evaluate me. I felt comfortable with my health care visit being through the teleconsult system. Having this system available made it easier for me than having to drive to Charleston to see the MUSC provider. I would rather go to Charleston to see the MUSC provider in person. I would not have been able to see the MUSC provider without taking part in the tele-consult clinic. I will have better health care results by taking part in the tele-consult clinic. MUSC Provider Statement I understood what the MUSC provider was saying. The MUSC provider could understand what I was saying. I could easily ask questions. The MUSC provider listened to me. The MUSC provider offered a solution to my care. Don t Know/ Not Applicable Don t Know/ Not Applicable Statement Team of providers (Your local provider + MUSC provider) Don t Know/ Not Applicable I liked having my own doctor in the room with me during the teleconsult visit. I am happy that my provider is working with an MUSC provder using a tele-consult visit. Statement Overall opinion of the tele-consult visit Don t Know/ Not Applicable Overall, I am very satisfied with the tele-consult visit. I am willing to take part in another tele-consult visit. What did you like best about the tele-consult visit? What did you like least about the virtual tele-consult visit? How can we make a virtual tele-consult visit better for you? Return to Laura Langston, MUCS VTCC Coordinator. Email: langstl@musc.edu. Fax: 843-792-1891. Address: MUSC-Department of Surgery, 96 Jonathan Lucas Street, MSC 613, Charleston, SC 29425-6130 Survey 2 of 2

A. Notifier: B. Patient Name: C. Identification Number: Advance Beneficiary Notice of Noncoverage (ABN) NOTE: If Medicare doesn t pay for D. MNT below, you may have to pay. Medicare does not pay for everything, even some care that you or your health care provider have good reason to think you need. We expect Medicare may not pay for the D. MNT below. D. E. Reason Medicare May Not Pay: F. Estimated Cost Medical Nutrition Therapy (MNT) If you do not have diabetes, kidney failure, or have had a kidney tranplant within 3 years, Medicare maynot pay. If your Medicare plan is not within network with MUSC, Medicare may not pay. $50-65 per half hour WHAT YOU NEED TO DO NOW: Read this notice, so you can make an informed decision about your care. Ask us any questions that you may have after you finish reading. Choose an option below about whether to receive the D. MNT listed above. Note: If you choose Option 1 or 2, we may help you to use any other insurance that you might have, but Medicare cannot require us to do this. G. OPTIONS: Check only one box. We cannot choose a box for you. OPTION 1. I want the D. MNT listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn t pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles. OPTION 2. I want the D.. MNT listed above, but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed. OPTION 3. I don t want the D. MNT listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay. H. Additional Information: This notice gives our opinion, not an official Medicare decision. If you have other questions on this notice or Medicare billing, call 1-800-MEDICARE (1-800-633-4227/TTY: 1-877-486-2048). Signing below means that you have received and understand this notice. You also receive a copy. I. Signature: J. Date: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0566. The time required to complete this information collection is estimated to average 7 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850. Form CMS-R-131 (03/11) Form Approved OMB No. 0938-0566