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Patient/Client Consent Form

This form is to obtain your consent to participate in telehealth physical therapy. Physical therapy care provided via telehealth is the utilization of technology by licensed physical therapy providers to provide physical therapy services including evaluation and treatment to patients located in remote locations. Telehealth services include telephone consultation and/or online audio/video consultation. Dr. Kevin Castro, PT uses online audio/video service through encrypted, private meetings between the physical therapist and patient to protect patient privacy. This online video service meets current regulations for HIPAA compliance. I understand that the evaluation and treatment of current medical condition(s) using a telephone consultation and/or synchronous audio/video consultation is under the Physical Therapy scope of practice similar to a clinic visit and will be carried out by a licensed practitioner.

Nature of Telehealth session: Details of your medical history will be discussed, your status will be evaluated and you will be treated through the use of interactive video, audio, and telecommunication technology. Video, audio, and/or photo recording may be taken of you during the telehealth consult for coaching or treatment purposes only. Your therapist will determine whether your specific clinical needs are appropriate for a telehealth encounter. I understand that the Telehealth sessions differ from direct patient/health care provider visit due to the fact that I will not be in the same room as my health care provider. This hands-off session(s) will consist of detailed discussion regarding my condition and may include a visual assessment of my movement patterns, balance, and range of motion. I agree to the Therapist’s plan of care which may be modified for telehealth. I understand that I will be given a home exercise program and recommendations to allow me to progress towards my goals.

Benefit: Improved access to care by enabling you to remain in your home while receiving physical therapy. As a result of this session I may experience an improvement in my symptoms and an increase in my ability to perform daily activities. I may experience an increase in strength, awareness, flexibility, and endurance in my movements. I should gain a greater knowledge about actively maintaining my health and the resources available to me.

Possible Risks: Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment and technologies. In very rare events, security protocols could fail, causing a breach of privacy of personal medical information. I may experience an increase in my current symptoms, or an aggravation of my existing injury or condition. This discomfort is usually temporary; if it does not subside in a reasonable time period, I agree to contact my physical therapist.

Medical Information & Records: All existing laws regarding your access to medical information and copies of your records apply to this telehealth session. Healthcare information may be shared with other individuals for scheduling and billing purposes. Identifiable images or information for this telehealth interaction will not be shared with any other parties without your consent. You will not record the telehealth session (audio or video recording) unless given the consent of your therapist.

Confidentiality: Reasonable and appropriate efforts have been made to eliminate confidentiality risks associated with telehealth sessions, and all existing confidentiality practices under state and federal law apply to information disclosed during this session

Rights: You may withhold or withdraw your consent to the telehealth consultation at any time for any reason. You do not have to give a reason for withdrawing from telehealth and it will not affect your right to future care or treatment. If you experience a medical emergency, you will be directed to dial 9-1-1 immediately.

Patient Consent: I have read this document carefully and understand the risks and benefits of the telehealth consultation and have had my questions regarding the procedure explained. I hereby give my informed consent to participate in a telehealth consultation under the terms described herein.

Parental Consent: If under the age of 18, parental consent is required for all treatment and personal training services. Parental signature is required below.

Other Information: I understand that it is my responsibility to ensure that I am in a private space during my telehealth session in order to maintain the privacy of my health information. I understand the Physical Therapist will also conduct the session in a space that is conducive for keeping health information private and maintain professional guidelines. In an emergent consultation, I understand that the responsibility of the telemedicine consulting specialist is to advise my local practitioner and that the specialist’s responsibility will conclude upon the termination of the telehealth connection. I agree to participate in all Physical Therapy telehealth services including telephone consultations and/or online video consultations through HIPAA compliant platform.

Thanks for submitting!

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