The purpose of this form is to obtain your consent to participate in a telehealth consultation for outpatient therapy services with a licensed therapist from SEPT Physical Therapy.

The Nature of A Telehealth Therapy Visit:

• The therapist will use a HIPAA Compliant, interactive video/audio communication platform to treat you.
• NOTE: During the Covid-19 Emergency, these restrictions have been loosened to allow less secure options (i.e., Facetime provided you are aware of the additional risk).
• The therapist may perform a “virtual” examination
• The therapist will not be able to perform hands on treatment such as manual therapy and a telehealth visit may not substitute for all your therapy needs.

Expected Benefits Include:

• Improved access to therapy services from the patient’s home
• Obtaining expertise from a specialist
• More efficient physical therapy intervention
• Continued progress on your therapy plan of care

Risks:

• In rare cases, information transmitted (i.e. a poor video connection) may not be sufficient to allow for appropriate clinical decision making by the therapist.
• Technical difficulties could result in a missed or incomplete visit which the patient or provider may choose to reschedule.
• Delays in evaluation or treatment may occur due to equipment deficiencies or failure.

Medical Information and Records:

All existing laws regarding your access to medical information and copies of your medical records apply to these telehealth visits.  Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient information.

Confidentiality:

Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with a telehealth visit, and all existing confidentiality protections apply to information disclosed during our telehealth visits.

Rights:

You may withdraw consent to telehealth visits at any time without affecting your right to future care or treatment.

I have read and understand the information provided above regarding therapy telehealth visits.  I understand its contents including the risks and benefits.  I have discussed the applicability of telehealth to my plan of care, and my questions have been answered to my satisfaction.

Financial Statement:

SEPT Physical Therapy is operating under the assumption that insurance companies will temporarily update their restrictions and reimburse for the telehealth PT/OT services which would mandate that we collect Co-Pays, Co-Insurance, and deductibles at the time of service as usual. If Telehealth treatments for PT and OT are not covered services for my condition, the cost of the visit will not exceed the amount of the co-payment under my plan and the paid co-pay will be applied to that visit.