On March 19, 2020, Christopher C. Krebs, the director of the US Department of Homeland Security Cyber Security & Infrastructure Security Agency issued a mandate in collaboration with other federal agencies and the private sector that identifies certain medical and health care, providers as "Essential Critical Infrastructure Workers critical to the public health and safety, as well as economic and national security.

To this end, Sunrise Physical Therapy Services, Inc. in an effort to ensure we can continue to provide those essential physical therapy services to our patients/clients have determined that we will continue to operate and see patients, in the office, on a limited basis, based exclusively on a determination of a medical or physical therapy need that cannot be addressed by way of telehealth, and to ensure that we continue to provide the best and most comprehensive care and treatment to our patients/clients.

 

We will be operating with the following restrictions:

• If you wish to consult a therapist to determine if your condition is appropriate for continued in person treatment please immediately contact Sunrise Physical Therapy Services, Inc., and a Physical Therapist will contact you within 24 hours for telephonic evaluation of whether or not your condition is appropriate for continued in office therapy, or whether your condition may be more appropriate and amenable to telehealth evaluation and therapy.

• If it is determined after a discussion with your Physical Therapist, that an in office visit would be appropriate, we will be adhering to The CDC guidelines to ensure the health, safety, and well-being of both our patients, our physical therapists, physical therapy assistants, and staff. This will include a requirement that each patient comply with additional new office policies, guidelines, and restrictions.

• Every patient will be required to sign an additional consent form to continue in office treatment and evaluation.

• Every patient will undergo a screening evaluation at each treatment session and will be transitioned to telehealth if appropriate.

• Every patient will be required to fill out a Covid-19 Infectious Disease Screening prior to each visit and it is critically important that the patient be honest and forthright in the responses to this form.

• Every patient will cooperate with additional critical antibacterial and hygienic procedures in the office as dictated by the Physical Therapy staff to ensure maximum protection for all involved including waiting in the car until the appointment is called.

• The patient/client further agrees that if, at any time you become symptomatic or test positive for Covid-19, they will immediately contact Sunrise Physical Therapy Services by phone and e mail to advise the staff of their current medical status.

 

Acknowledgement: I have read this consent form and understand the risks involved, and agree to fully cooperate, participate in all physical therapy procedures, and comply with the established plan of care.

It is my desire to participate in telehealth treatment/visits through Sunrise Physical Therapy Services, Inc.. I have agreed to voluntarily participate in telehealth therapy visits and recognize that there are limitations to the services available through telehealth services compared to an inperson visit. This may include, but is not limited to the inability of the therapist to perform an in
person hands-on examination, assessment, observations, feedback, and treatment.

Potential Risks: I understand that it is not possible to accurately predict my response to a specific telehealth therapy modality, procedure, or exercise protocol. Therefore, Sunrise Physical Therapy Services, Inc. can not guarantee what your reaction might be to a specific treatment, nor does it guarantee that the treatment will help resolve the condition you are seeking treatment for during these telehealth visits. I understand that there may be other risks not known or not reasonably foreseeable at this time. Furthermore, there is a possibility that the telehealth physical therapy treatment may result in aggravation of existing symptoms and may cause pain or injury. I understand that medical attention will not be immediately available in the event it should be needed, and will seek care from my personal physician or other health care provider if I have any concerns about my physical condition or health.

Telehealth: I understand this telehealth visit entails use of digital photography, digital interactive sessions, and videotaping for my telehealth therapy visit. I acknowledge that Sunrise Physical Therapy Services, Inc. has used reasonable efforts to implement the appropriate privacy and security measures through a third-party vendor to protect my protected health information (PHI). I hereby acknowledge and agree that there are potential risks associated with this type of telehealth therapy notwithstanding these measures. Therefore, I hereby release and hold Sunrise Physical Therapy Services, Inc. harmless if any privacy, technical, security breach or unauthorized release of PHI information should these protection measures fail for any reason. I authorize the release of
my telehealth therapy medical information to appropriate third parties as necessary for any insurance, or medically related purposes.

Acknowledgement: I have read this consent form and understand the risks involved in physical therapy and agree to fully cooperate, participate in all telehealth physical therapy procedures, and comply with the established plan of care.

I understand that I am a patient of Sunrise Physical Therapy Services, Inc. and their independent physical therapy practitioners, physical therapy assistants and staff. I am aware of the Covid-19 pandemic, the fact that the disease can be highly communicable, and that social distancing with a minimum of 6 foot distance is recommended by the Federal Centers for Disease Control. I am also
aware of the rules, restrictions, and guidelines set forth by Governor Gavin Newsom in the state of California respect to living social interaction and that the recommendation is for all individuals to shelter in their own home.

COVID-19 Risks: I understand and acknowledge that I have voluntarily have made the decision to continue to receive hands on in-office physical therapy at the present time. I acknowledge that I am fully aware of the Covid-19 pandemic, and am informed and aware of all the available medical literature and information available from the CDC, and all available digital resources including the news and the Internet relative to the pandemic.

Cooperation with treatment: The purpose of physical therapy is to treat disease, injury and disability by examination, evaluation, diagnosis, prognosis, and intervention by use of rehabilitative procedures, mobilization, massage, exercises, and physical agents to aid the patient in achieving their maximum potential within their capabilities and to accelerate convalescence and reduce the length of functional recovery. All procedures will be thoroughly explained to you before you are asked to perform them. In order for physical therapy treatment to be effective, I understand I need to come to scheduled appointments unless there are unusual circumstances. I understand and agree to cooperate with and perform the home physical therapy program intended for me.

No warranty: Response to physical therapy intervention varies from person to person; so it is not possible to accurately predict your response to a specific modality, procedure, or exercise protocol. Sunrise Physical Therapy Services, nor your therapist, can guarantee what your reaction will be to a specific treatment, nor can we guarantee that the treatment will help resolve the condition that you are seeking treatment for.

Potential risks: Furthermore, there is a possibility that the physical therapy treatment may result in aggravation of existing symptoms and may cause pain or injury. I understand that it is very important to communicate any concerns with my treating physical therapist throughout my treatment.

Potential benefits: It is your right to decline any part of your treatment at any time before or during treatment, should you feel any discomfort or pain or have other unresolved concerns. It is your right to ask your physical therapist about the treatment they have planned based on your individual history, physical therapy diagnosis, symptoms, and examination results. Consequently, it is your right to discuss both the potential risks and benefits involved in your treatment.

Acknowledgement: I have read this consent form and understand the risks involved in physical therapy and agree to fully cooperate, participate in all physical therapy procedures, and comply with the established plan of care. I authorize the release of my medical information to appropriate third parties.