Sample Intake Form

Physician Moonlighting Opportunities

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I would like to welcome you to the future of clinical Orthopedic medicine, and thank you for exploring MoonlightOrtho® as a viable option to deliver high quality Orthopedic patient care, while easing into this new era of telehealth/telemedicine. As physicians, we have likely all been practicing a "version" of telemedicine for years when responding to e-mails and text messages/photos on our cell phone, with patients asking "Hey Doc, what's going on with my ..." With MoonlightOrtho® we can now monetize and track those interactions within a HIPPA compliant, web-based software service. MoonlightOrtho® is a triage tool, that is, just another "arrow in our quiver" to offer patients the convenience that they are demanding.

As Orthopedic Surgeons we are all trained to recognize certain patterns of pathology, and with experience can often do so without ever laying hands on the patient. MoonlightOrtho® is ideal for those patient types. The platform was built with the average physician and geriatric patient in mind, neither of which like ‘clicking a lot of buttons on the computer’! As busy physicians and surgeons we do not have time to pull away for a live or real-time video interaction, as offered by other telehealth platforms; which is why MoonlightOrtho® relies on Asynchronous Video Telecommunication. We've also built-in prescribing/referral capabilities, and the MoonlightOrtho® platform even functions well as a stand-alone EMR. Additional unique and user-friendly features of MoonlightOrtho® include: the ability to "Decline" a patient if you feel that their Orthopedic condition is better treated in an office-based setting, and the ability to "Disable" yourself temporarily within the platform if you will be on vacation or otherwise unavailable.

MoonlightOrtho® can easily be integrated into your existing practice, or utilized as a stand-alone service. It can function as a procedure generator, a convenience option for local or remote patients, and as an ancillary income source. You may see patients in any state that you are licensed, and an average "visit" takes just a few minutes. Additionally, providers have up to 36 hours to "see" and respond to patients at your convenience (maybe during turnover while the OR crew is taking way too long!). Finally, since we only accept CASH, no "over documentation" is required, and we do all the billing for you!

We’ve streamlined the application process; simply review the PRIVATE CONTRACTOR AGREEMENT and fill out the one-page form within the Provider Registration Tab and you’re good to go! And for those providers who no longer carry malpractice insurance, are retired, or who just want to beef up their advertising and self-promotion, we additionally offer the Curbside Consult visit, which is an informal, advice-only service to our patients.

We’ve streamlined the application process; simply review the PRIVATE CONTRACTOR AGREEMENT and fill out the one-page form within the Provider Registration Tab and you’re good to go! And for those providers who no longer carry malpractice insurance, are retired, or who just want to beef up their advertising and self-promotion, we additionally offer the Curbside Consult visit, which is an informal, advice-only service to our patients. Thank you again for your interest and your open mindedness, I think you will find MoonlightOrtho® a much better way to Moonlight...and advertise, and generate patients/procedures, and extend your catchment area, and see Post-Op patients, and collect ancillary income! For more information, please do not hesitate to e-mail me directly at de@moonlightortho.com.

Dr. David E. Eisenhauer
Board Certified Orthopedic Surgery, CAQ-H
Dual Fellowship trained, Shoulder/Elbow & Hand

Private Contractor Opportunity
Private Contractor Opportunity

FAQs for MoonlightOrtho® Providers

Malpractice coverage is left up to the individual provider. Please check your existing policy, as roughly 50% of malpractice carriers today currently extend telehealth coverage automatically or upon request. However, we do offer a stand-alone, telehealth-only umbrella policy via MoonlightOrtho®, for a very reasonable rate. MedPro carries our malpractice and can write policy in all 50 states. The stand-alone policies are typically very affordable when going through MoonlightOrtho®, and average just $200 - $500 per 12 month period, including tail coverage.

Office based providers will then use their existing malpractice coverage for any patients that need on-going, office-based care.

Yes! Providers can earn an extra $3,620/month, seeing just 1 New Patient Visit per day with MoonlightOrtho®. That’s $43,435 per year, based on seeing New Patient Visits at $159/visit. Your income could be even more when seeing Second Opinions at $279 per visit or Concierge Visits at $299, and/or if you are doing a higher volume. (volume by state is not yet established)

With the Private Contractor provider model, there are no sign-up fees, monthly fees, or minimums - if you see patients we charge a flat 25% overhead to your collections for web maintenace, data storage, advertising, etc. However, if you would like to utilize the platform for the convenience of seeing post-operative patients only, and no fees are collected, then NO overhead will be charged to you. There truly is no downside to signing up for a provider account on MoonlightOrtho®.

MoonlightOrtho® can help you or your practice in three ways:

1.) This can be a marketing tool, as we are a unique and cutting edge medical technology which can set you and your practice apart from the competition

2.) This can act as a procedure generator or surgical case generator for patients in your immediate catchment area, which you may not have otherwise seen.

3.) This can be a pure ancillary income, either personally or for your practice as a whole

Yes. In fact, we encourage that. MoonlightOrtho® patients are YOUR patients.

With a New Patient visit there will be 3 interactions in total:

(1) First the patient will upload their pertinent information, including video.

(2) Next the provider will review and respond to the patient with an Assessment and Recommendation(s), along with a return video.

(3) Finally the patient may have an opportunity to answer any questions or respond to the provider’s recommendations.

There are a few different options: first of all, if you want to give your personal contact information (email or phone number) you are certainly welcome to do so. Next, there is a “chat bubble” feature found next to each patient Encounter, this allows you to interact with the patient in a HIPPA compliant manner and on a more limited basis. Finally, patients may register for a Return Visit via MoonlightOrtho®, or follow up in the provider’s office for any in-depth or ongoing care needed.

This is a tricky question and perhaps a grey area. We have placed a Disclaimer disallowing patients with the Medi insurances, as the telehealth laws have recently changed for the government payors. Our stance may change in the very near future, but for now, those patients will be directed away from MoonlightOrtho®.

No. That’s the beauty of MoonlightOrtho®, we have a patent-pending Asynchronous Video Telecommunication process, which allows the patient to upload a short video at their convenience, then the provider can review the video and upload a return video at their convenience.

Patients can search by provider name, or by condition and state; this option will give a dropdown list of all providers in the patient’s state.

Absolutely, just like you would any other patient. There is a prescription writing task bar within the Provider Dashboard that allows you to print off a generic Rx sheet, Lab or Imaging Orders, Physical/Occupational Therapy Orders or a Work/School note. You will then just fill out the patient’s information and upload a PDF to MoonlightOrtho®, which can be emailed or faxed to the patient, or directly to the facility (pharmacy, lab, PT, etc.). A provider can do the same with their own prescription pad or any set of pre-made ordering forms that they have. (MoonlightOrtho® recommends not prescribing narcotics to your telemedicine patients.) Eventually we will be tied in with a telehealth prescription company such as eRx. Please check your individual state at http://www.cchpca.org/ for any prescribing restrictions.

MoonlightOrtho® leaves this up to the individual provider; if you want to do the footwork, or task it to someone in your office, then you are welcome to do so. However, patients are prepared for no pre-auths, as they will see Disclaimers stating: “Even if an MRI is ordered, it may not be authorized by your insurance without a physical exam” and “SORRY, we can not preauthorize insurance”.

We anticipate that most patients utilizing MoonlightOrtho® will seek out cash-pay imaging facilities, just as they found you…they just needed a provider to order the study. Our sister company FastXray.com is currently partnering with a very large network of Imaging Centers around the country that are able to offer MoonlightOrtho® patients cash-pay orthopedic imaging options .

A video teleconference obviously can never replace a physical exam, however MoonlightOrtho® can fill a void in healthcare, that is, this service may be well suited for the busy patient who just wants to be “triaged” and offered some early treatment options or imaging modalities, thus either resolving their minor problem, or giving a more complete picture if/when they do need to come in to your clinic for an in-person visit. The MoonlightOrtho® patient may have done some of their own research and they just need a clinician to help confirm the diagnosis. We as providers have all been doing this for years, via telephone, Skype or Facetime, treating family, friends or even friends of friends based upon our years of experience and seeing frequent patterns with common pathologies. Now you have an avenue to get paid for it!

Once the patient has registered and uploaded their information the MoonlightOrtho® provider gets a “ding” in their Dashboard, as well as an email reminder. The patient will expect a response within 24 – 36 hours. We recommend setting up a separate email acct to handle your MoonlightOrtho® patients, so that they don’t “get lost in a sea of e-mails”. This is also an easy way to communicate with your patient, while keeping your primary email blinded to your patients, if/when you need to have continued communication with the patient, or send a prescription or order.

Yes, a “Decline” function/button is located within your provider dashboard and should be used at your professional discretion. The money will be refunded to the patient and they will be told to “Please search another provider.”

We want to give our MoonlightOrtho® patients the ability to do their due diligence, as some patients might be weary of ‘Seeing an online doctor.’ When you upload your CV, please do not list any sensitive, personal or private information, so this can be more of a “Bio”. Please do, however, list your office address and contact information, so that patients may seek follow up care in person if they desire.

Yes. This can be done a couple of different ways:

1.) We can license you the software platform and MoonlightOrtho® then becomes yours to run any way you like (you may change the pricing, include post-op visits, etc.)

2.) You may have a link added to your practice website, directing patients to MoonlightOrtho®, thereby giving your current and future patients an after- hours, concierge-style, online Orthopedic ‘Urgent Care’ option. The profits of MoonlightOrtho® may then be shared among your group as group ancillary, or go directly to whomever does the consult.

3.) You may individually utilize MoonlightOrtho® to “fill the gaps” in your schedule; for example, if you have a No-Show patient, or when you are sitting in the OR lounge during turnover; at which point MoonlightOrtho® can function as another personal source of income.

Yes. Within your provider Dashboard there is an option to temporarily “Disable” yourself as a provider within the system.

No. Medicine is considered practiced in the state which the patient resides. So, a provider must be licensed in that state. As a provider you can be anywhere that you have access to a computer however.

Yes. As long as your license is unrestricted and up to date.

Telemedicine laws currently vary by state, please check on your individual state at http://www.cchpca.org/. In general, however, most laws apply to insurance reimbursement requirements; this is not an issue with MoonlightOrtho®, as we are a cash pay, fee-for-service provider.

There is no minimum or maximum, and no charge if you don't see any patients during a particular time period. We only charge you a flat "overhead' if you see a CASH paying patient. So, if you would like to utilize the platform for the convenience of seeing Post-Operative patients only, and no monthly fees are collected, then NO overhead will be charged to you! There truly is no downside to signing up for a provider account on MoonlightOrtho®...

No, not in the traditional sense. We do not require you to ‘click a lot of buttons’, as there is no coding or billing within MoonlightOrtho®. However, your patient’s records, and any communication, including prescriptions, are safely stored in our HL 7 certified and HIPPA compliant server indefinitely, just as they would be in any other EMR. The records are available anytime to patients or providers via a secure portal. Furthermore, patients and providers can print a PDF of the patient Intake Form (essentially an H&P) for additional paper records, or to hand carry to an office visit.

Yes! Unfortunately, the attorneys have advised us against levying a "convenience charge" for those patients within the global period, so it is still a 'No-Pay' visit type, just as it in an office based setting. However, seeing the simple Post Op patient via telehealth may open up another slot in your day to see a paying patient in your clinic. For patients to utilize the Post Op Visit type on MoonlightOrtho®, strict permission HAS to be given by their surgeon, at their initial post-op office visit.

Just as it sounds, this is a phone call-only visit type, basically giving the patient "advice" on a certain topic(s). A Phone Consult allows patients to discuss anything regarding the field of Orthopedics. The patient may have questions regarding the use of orthobiologics such as stem cell or platlet rich plasma (PRP) injections, or they may have questions or want advice concerning new or cutting edge technologies or surgical procedures. The Phone Consult will include 20 minutes of uninterrupted conversation with the MoonlightOrtho® provider. No documentation is preformed as there is no exchange of written or video information between the patient or provider. This is an on-demand, phone call-only visit, that you can schedule with the patient at YOUR convenience.

YES! MoonlightOrtho® is available to International providers and patients alike. For US based physicians, providing medical care to patients living abroad is up to the individual provider and is not regulated by our government. If you are a US licensed provider living abroad, then you can see patients in the states that you are licensed. However, if you are not a US licensed Orthopedic Surgeon, but carry medical licensure and are Orthopedic or Sports Medicine speciality trained in a country outside of the United States, you may register for a MoonlightOrtho® Provider account and see patients in your home country or abroad.

Yes! Please see the Licensing Opportunity tab above to see how we can build you or your group your own one-off appearing, semi-custom telehealth website as a monthly lease, tying seamlessly into your existing practice website. Also, for international licensing opportunities, please see the question above with more detail.

Our team of attorneys has done a very good job of spelling out which patients should NOT utilize the services of a MoonlightOrtho® provider, by requiring patients to physically check a box AND click on “I Agree” to a Disclaimer page, a User Agreement and Patient Consent Form, and a Notice of Privacy Practices page before proceeding with registration. Hopefully patients will only self-refer if appropriate, however, we know that may not always be the case. If a patient ‘slips through the cracks’, as the provider, you may respectfully decline to see the patient, with a built-in “Decline” function, and the patient will be told to “Please search another provider”, at which point we will refund the patients money.

Ideally no, as most of these patients will be screened out by the Disclaimer page; however, “cold trauma” may be seen at the provider’s discretion (distal radius fractures, metatarsal fractures, etc.)

Monthly, by check for now. Direct deposit is coming in the near future.

Yes, please do! Most of our providers have a full-time practice or are locums physicians. MoonlightOrtho® does not want to restrict you or your practice in any way.

There are two options: a stand-alone Ask-An-Ortho Provider account, meant for those providers who do not wan to practice telemedicine or who do not carry malpractice/are retired, etc.; additionally, the forum is open to all practicing MoonlightOrtho® providers on the platform as well. The Ask-An-Ortho forum is a FREE service to patients, where they may ask general, orthopedic-related questions and receive generic and general, non-patient specific ADVICE ONLY from a MoonlightOrtho® provider. This is NOT considered the practice of medicine, so any provider may respond to any patient across state lines, and no malpractice insurance is required! However, our intent is to match patients and providers geographically nearby, for advertising purposes for the provider (in hopes that the patient will then register for a PAID visit type via MoonlightOrtho® or follow-up in office with the local provider).This is a FREE service to providers and patients alike.

No (sorry). We believe it takes a couple of years out on your own before you are comfortable with making a diagnosis in a setting such as MoonlightOrtho®.

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MoonlightOrtho® Disclaimer

MoonlightOrtho® is an online, telemedicine technology platform offering concierge-style orthopedic medical services only. WE DO NOT OFFER EMERGENCY MEDICAL SERVICES. YOU SHOULD NOT UTILIZE THE SERVICES OF A MOONLIGHTORTHO® PROVIDER IF YOU HAVE ANY OF THE FOLLOWING:

  1. (1)

    an open wound more than a superficial scrape, with or without exposed deep tissue or bone, or a deformity of a joint or extremity at the area of pain or concern;

  2. (2)

    a red/hot joint or extremity with or without swelling;

  3. (3)

    acute onset of numbness or tingling at the area of pain or concern;

  4. (4)

    significant pain or excessive swelling of a joint or extremity;

  5. (5)

    if you sustained a fall from a height above ground level or were involved in a motor vehicle accident or other high-speed injury;

  6. (6)

    if you sustained a penetrating type trauma, such as a stab or gunshot wound;

  7. (7)

    if you have ANY additional injuries, such as abdominal or head pain or trauma;

  8. (8)

    if you are running a fever, have chills, nausea, vomiting, diarrhea or other signs or symptoms of infection or a generalized illness;

  9. (9)

    if you have experienced night sweats or unintentional weight loss;

  10. (10)

    if you have any other significant medical issues or conditions that may complicate your orthopedic problem(s); such as a history of cancer, uncontrolled diabetes, uncontrolled rheumatologic disease or inflammatory arthritis, or any history of chronic infections;

  11. (11)

    if a reasonable person would otherwise seek in-person medical care with their Orthopedic Surgeon, Primary Care Physician, or their local Emergency Department

If you have any of the conditions described above you should go directly to an Emergency Room, Urgent Care center or your local Primary Care Physician or Orthopedic Surgeon, as appropriate. If you are not able to get to one of the facilities listed above, you should call 911 from your home or mobile phone.

  1. Additionally, at this time we are not able to see patients with Medicare or Medicaid due to governmental restrictions of fee-for-service telemedicine practices

MoonlightOrtho® users are evaluated solely via telemedicine, and no in-person examination is performed. Thus, some orthopedic conditions and pathology may be difficult or impossible to sufficiently diagnose or treat. All assessments and recommendations, including but not limited to studies, such as lab and imaging, as well as any prescriptions, are ordered remotely based on each individual patient’s response to a medical questionnaire and asynchronous video telecommunication. For difficult or unusual orthopedic problems, a thorough physical exam, by a qualified orthopedic surgeon, may be needed.

Certain soft tissue pathology such as sprains, strains, tears, contusions or injury to nerves, arteries, veins, or tendons, as well as limb threatening compartment syndrome (severe swelling of an extremity that may lead to amputation of the limb) may not be easily diagnosed via a telemedicine process alone, and an in-person office or Emergency Department visit, with a healthcare provider, is recommended. Additionally, occult fractures, certain bone tumors, and other bony pathology may not be easily diagnosed via a telemedicine encounter and an in-person office visit or emergency department visit with a healthcare provider is recommended. This may be especially true for certain pediatric fractures where there may be a fracture through the physis (growth plate) which is not visible on X-ray alone.

For all imaging studies interpreted as "negative", when patients experience pain, MoonlightOrtho® recommends an in-person follow up visit with your healthcare provider to rule out occult fracture or other bony or soft tissue abnormality that may have been “missed” by the imaging modality, or under read by the radiologist. For all lab studies interrupted as “normal”, when patients are symptomatic, MoonlightOrtho® recommends an in-person follow up visit with your healthcare provider to rule out pathologic conditions not detected by the lab, for various reasons, not limited to lab error.

It is the responsibility of the patient to arrange for follow-up care after an imaging or lab study is preformed, as our providers may not routinely have access to the results and may not be able to call patients with normal or abnormal findings. Follow-up may be with the provider of your choice, including your MoonlightOrtho® provider, your local Orthopedic Surgeon, or your Primary Care Physician.

If medications are prescribed by a MoonlightOrtho® provider it is the patient’s responsibility to take the medications responsibly and as prescribed. If you have an adverse reaction to medication prescribed by MoonlightOrtho® provider, MoonlightOrtho® recommends that you go immediately to your local Emergency Department for an in-person evaluation and treatment with a healthcare provider. Please understand that prescribing restrictions vary by state, and in some states a prescription my not be possible via telemedicine.

This short list of potential problems that could arise, or pathologic conditions that could go undiagnosed or improperly treated, when utilizing the services of a MoonlightOrtho® telemedicine provider, is meant to serve as a WARNING to patients to use our services responsibly, it is by NO MEANS an all-encompassing list.

Please do your due diligence when choosing a MoonlightOrtho® provider. Most of our providers are board-certified Orthopedic Surgeons in a private or group practice within the state they are seeing MoonlightOrtho® patients. However, some surgeons may be locums or military and be licensed in the state that they are seeing MoonlightOrtho® patients, yet not have a physical address or clinic in that state. If in-person follow-up care is anticipated after the New Patient MoonlightOrtho® visit, please research your provider’s physical location by reviewing their Curriculum Vitae. Additionally, some of the MoonlightOrtho® Sports Medicine physicians may be Internal Medicine, Emergency Medicine, Primary Care or PM&R Sports Fellowship trained, and as such, can not provide surgical services. Podiatry services are offered by our MoonlightOrtho® providers with a Doctorate of Podiatric Medicine (DPM).

Be aware that your MoonlightOrtho® provider has the right to “Decline” any visit with any patient, solely at the MoonlightOrtho® provider’s discretion. In this instance a full refund will be made to the patient and the patient may seek care with another MoonlightOrtho® provider in their area, or choose to be seen by their local provider of choice in an office-based setting. Please understand that this is typically because the MoonlightOrtho® provider feels that the patient may be a poor candidate for telemedicine services, and that the patient may be better suited for an in-office visit.

This is only ONE of FIVE legal documents that patients will encounter on the MoonlightOrtho® website during their registration process; these are meant as protection for patients and providers alike. Along with this document, the others require a physical “checkbox” and “I Agee” click button to proceed, which equals a signature for medical/legal purposes. If you would like a copyrighted version of ALL medical/legal documents prepared by the MoonlightOrtho® attorney team, please e-mail: de@moonlightortho.com or call 1-833-FASTXRAY.

Sample Intake Form

Provider Registration

Please enter your data to register.
  Check here if your Orthopedic practice is in a country other than the United States.

Check here for a Curbside Consult-ONLY account. Clicking this box ONLY allows you to see Curbside Consults, and no other Visit types. Any current or retired physician, or advanced practitioner, may sign up for this type of account, NO malpractice insurance is required!


By placing your initials/date and clicking ‘I Agree’ I acknowledge that I am electronically signing a legally binding contract, MOONLIGHTORTHO® PRIVATE CONTRACTOR PHYSICIAN SERVICES AGREEMENT, between myself as a participating physician and MoonlightOrtho®, INC., a Delaware based company.

By checking this box I acknowledge and agree that I have read/reviewed and understand the information available to me at moonlightortho.com, and I feel comfortable offering a professional medical opinion via telehealth/telemedicine. I have additionally reviewed the Terms provided within the MOONLIGHTORTHO® PRIVATE CONTRACTOR PHYSICIAN SERVICES AGREEMENT

By checking this box I acknowledge and AGREE that I have read, reviewed & understand the information available to me at moonlightortho.com, including the Terms and Conditions, and I feel comfortable rendering a professional medical opinion and/or medical advice via a telehealth/telemedicine platform/setting. Additionally, I understand that a flat 50% overhead, after collections, will be charged to all Curbside Consults.