I understand that telehealth is the use of electronic information and communication technologies by a health care provider; I hereby consent to ETC Physical Therapy providing health care services via telehealth.
I understand that the laws that protect privacy and the confidentiality of medical information also apply to telehealth. As always, your insurance carrier will have access to your medical records for quality review/audit.
I understand that I will be responsible for any payments that apply to my telehealth visit.
I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time without affecting my right to future care or treatment.
I may revoke my consent orally or in writing at any time by contacting ETC Physical Therapy at 816-331-9111. As long as this consent is in force (has not been revoked) ETC Physical Therapy may provide health care services to me via telehealth without the need for me to sign another consent form.