Vital Physical Therapy Telehealth Consent Form

Please select all that apply*

1. I understand that my Physical Therapist recommends engaging in telehealth services to provide my treatment.
2. I understand this is out of necessity and an abundance of caution and has originated due to the Coronavirus (Covid-19) pandemic. This will continue until such time that we are able to meet in person. However, if agreed on by both the therapist and patient, telehealth treatment can continue post the Coronavirus (Covid-19) pandemic.
3. I understand that telehealth has been found to be effective in treating a wide range of disorders, and there are potential benefits including but not limited to easier access to care. I understand, however, that there is no guarantee that all treatment for all patients will be effective.
4. I understand that it is my obligation to notify my Physical Therapist of my location at the beginning of each treatment session. If, for some reason, I change locations during the session, it is my obligation to notify my Physical Therapist of the change in location.
5. I understand that it is my obligation to notify my Physical Therapist of any other persons in the location - either on or off-camera - who can hear or see the session. I understand that I am responsible to ensure privacy at my location. I will notify my Physical Therapist at the outset of each session and am aware that confidential information may be discussed.
6. I understand that there is a risk to my confidentiality. My Physical Therapist will take reasonable steps to ensure my privacy to the best of their ability.
7. I understand that it is my obligation to ensure that any virtual assistant, artificial intelligence devices or streaming devices, including but not limited to Alexa, Echo, or Netflix, will be disabled or will not be in the location where information can be heard.
8. I agree that I will not record either through audio or video any of the session, unless I notify my Physical Therapist and this is agreed upon.
9. I understand there are potential risks to using telehealth technology, including but not limited to interruptions, unauthorized access, and technical difficulties. I understand that stored data could be accessed by unauthorized people or companies and that my Physical Therapist will protect the data to the best of their ability. I understand some of these technological challenges, including issues with software, hardware, and internet connection, may result in interruption.
10. I understand that my Physical Therapist is not responsible for any technological problems of which my Physical Therapist has no control over. I further understand that my Physical Therapist does not guarantee that technology will be available or work as expected.
11. I understand that I am responsible for information security on my device, including but not limited to computer, tablet, or phone, and in my own location.
12. I understand that my Physical Therapist is not liable for any injury that might occur during my telehealth consult.
13. I understand that my Physical Therapist or I (or, if applicable, my guardian or conservator), can discontinue the telehealth consult/visit if it is determined by either me or my Physical Therapist that the videoconferencing connections or protections are not adequate for the situation.
14. I have had a conversation with my Physical Therapist, during which time I have had the opportunity to ask questions concerning services via telehealth. My questions have been answered and the risks, benefits, and any practical alternatives have been discussed with me.
15. doxy.me is the technology service we will use to conduct telehealth videoconferencing appointments. My Physical Therapist has discussed the use of this platform. Prior to each session, I will receive an email link to enter the “waiting room” until the session begins. There are no passwords or log in required.
16. I understand that in the event I do not show up, or cancel my appointment less than 24 hours in advance, I will be charged a $40 No Show/Late Cancellation fee.

BY SIGNING THIS DOCUMENT, I ACKNOWLEDGE:*

1. doxy.me is NOT an emergency service. In the event of an emergency, I will use a phone to call 9-1-1 and/or other appropriate emergency contacts.
2. I recognize my Physical Therapist may need to notify emergency personnel in the event they feel there is a safety concern, including but not limited to a risk to self / others or if my Physical Therapist is concerned that immediate medical attention is needed.
3. Though my Physical Therapist and I may be in virtual contact through telehealth services, neither doxy.me nor my Physical Therapist provides any medical, emergency, or urgent healthcare services or advice. I understand should medical services be required, I will contact my physician. If emergency services are needed, I understand I should call 9-1-1.
4. The doxy.me facilitates videoconferencing and this technology platform is not, itself, a source of healthcare, medical advice, or care.
5. I understand that the same fee rates apply fortelehealth as apply forin-person treatment. Some insurers are waiving co-pays during this time. It is my obligation to contact my insurer before engaging in telehealth to determine if there are applicable copays or fees that I am responsible for. Insurance or other managed care providers may not cover telehealth sessions. I understand that if my insurance, HMO, third-party payor, or other managed care provider do not cover the telehealth sessions, I will be solely responsible for the entire fee of the session.
6. During these times of the impact of Coronavirus (Covid-19) my Physical Therapist may not have access to all of my medical/treatment records. My Physical Therapist will make reasonable efforts to obtain records, but I understand and agree this may not be reasonably possible.
7. To maintain confidentiality, I will not share my telehealth appointment link or information with anyone not authorized to attend the session.
8. I understand that either myself or my Physical Therapist can discontinue the telehealth services if those services do not appear to benefit me therapeutically or for other reasons which will be explained to me.
9. I understand that my Physical Therapist will use the following contact information in an event of a crisis or emergency to assist in addressing the situation:

*

Check here if you accept these terms.

Emergency Contact Information (please provide someone close to your location):

Name:

Cell Number:

Work/Home Number:

Relation to Patient*:

I have read and understand the information provided above regarding telehealth, have discussed it with my Physical Therapist, and I hereby give informed consent to the use of telehealth.

Printed Name*

DOB*

Signature of Patient (or guardian/conservator)*

Date*

Vital Physical Therapy

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