Telehealth Informed Consent
Telehealth Informed Consent
The purpose of this informed consent is to obtain your permission to participate in a telehealth consultation for outpatient therapy services with a licensed therapist from SmartMovesPT / PTC Physical Therapy or PTCumberland Wellness. You might also be required to provide e-consent within our SmartMovesPT HIPPA complaint patient app prior to your first and any needed follow-up visits.
The purpose of this informed consent is to obtain your permission to participate in a telehealth consultation for outpatient therapy services with a licensed therapist from SmartMovesPT / PTC Physical Therapy or PTCumberland Wellness. You might also be required to provide e-consent within our SmartMovesPT HIPPA complaint patient app prior to your first and any needed follow-up visits.
Terms of Service
Terms of Service
Privacy Policy
Privacy Policy
Consent for Telehealth Services for Outpatient Physical Therapy
Consent for Telehealth Services for Outpatient Physical Therapy
The Nature of a Telehealth Therapy Visit:
- The Physical Therapist will use a HIPAA Compliant, interactive video/audio communication platform to treat you.
- The Physical Therapist may perform a “virtual” examination
- The Physical 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.
- The Physical Therapist will not record audio or video from your evaluation or treatments.
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.
(Your print consent will be required or e-consent through the patient application prior to first visit)
Signature: ________________________________ Date: __________________
The Nature of a Telehealth Therapy Visit:
- The Physical Therapist will use a HIPAA Compliant, interactive video/audio communication platform to treat you.
- The Physical Therapist may perform a “virtual” examination
- The Physical 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.
- The Physical Therapist will not record audio or video from your evaluation or treatments.
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.
(Your print consent will be required or e-consent through the patient application prior to first visit)
Signature: ________________________________ Date: __________________
