Physician Referral Request and Terms
Joe DiMaggio Children’s Hospital Second Opinion Program
A. The Service.
Through a secure platform, a District Physician will review the patients’ medical records and, during a telemedicine visit with the patient, will discuss the patient's condition in real-time. Depending on the District Physician's clinical judgment, a follow-up in-person visit to perform a physical examination of the patient independent of the medical records or additional diagnostic services may be required in order to provide the JSOP Services.
B. Terms and Conditions.
I acknowledge and agree that:
- My patient and I have discussed JSOP and I represent that I have obtained from my patient their permission and consent as required under the Health Insurance Portability and Accountability Act (HIPAA) and applicable state privacy law to provide their Patient Information (patient’s name, patient’s parent’s name, and their contact information: phone and email) to the District for the purposes of conducting a preliminary evaluation to determine if the patient meets the criteria to participate in JSOP.
- I have received from my patient his or her consent to receiving communications from the District regarding their participation in JSOP.
- I understand that the JSOP Services are not intended to provide consultation services between providers.