Telehealth Patient Consent

Please read the following before your first scheduled telehealth appointment. Your therapist is required to gain your verbal consent prior to any evaluation or treatment.

1. Purpose: The purpose of this form is to obtain your consent to participate in a telehealth encounter with your physical therapist for physical therapy services.
2. Nature of Encounter: During the encounter the following may occur:
   a. Details of your medical history will be discussed with you and with your referring provider if applicable.
   b. Video, audio and or photo recordings may be taken of you during the services; We are not saving any of the video, audio or photo data and this data will not be attached to your medical records.
3. Medical Information and Records:
   a. All existing laws regarding access to your medical record apply in telehealth.
   b. You understand that you have the right to restrict how your personal health information is used and disclosed for treatment, payment and administrative operations if you notify the practice in writing. By signing this form you hereby consent to the use and disclosure of your personal health information for communication with your referring provider if applicable and that you retain the right to revoke consent at any time.
   c. I would like my Physical Therapist to send copies of the records created in this telemedicine treatment to be shared with my primary care physician
   _____YES _____NO
4. Confidentiality:
   a. Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with telehealth services and applicable state laws apply regarding a telehealth encounter.
5. Rights:
   a. You may withhold or withdraw consent for telehealth services at any time without affecting your right to future care or treatment.
6. Risks, Consequences and Benefits:
   a. You have been advised of all the potential risks, consequences and benefits of telehealth services. Your physical therapist has discussed with you the information provided above. You have had the opportunity to ask questions about the information presented on this form and for telehealth services in general. All your questions have been answered and you understand the written information provided to you.

My signature below, or verbal approval documented in my chart, confirms that my health care provider has explained to me this form, how the video conferencing technology will be used and that it will not be the same as a direct patient/health care provider visit. I understand there are potential risks to this technology, including interruptions, unauthorized access and technical difficulties. I understand that I assume responsibility for all fall or injury risk while choosing to participate in this session. I understand that this visit is a continuation of my prior plan of care and all of the paperwork and forms signed at the initial evaluation apply to this visit.