Telehealth involves the use of audio, video, or other electronic communications to interact with you, consult with your healthcare provider and/or review your medical information for the purpose of diagnosis, therapy, follow-up and/or education. During your telehealth consultation, details of your medical history and personal health information may be discussed with you or other health professionals using interactive video, audio, or other telecommunications technology.  Additionally, a physical examination of you may take place, and video, audio, and/or photo recordings may be taken.  Electronic systems used will incorporate network and software security protocols to protect the privacy and security of  health information and imaging data and will include measures to safeguard the data to ensure its integrity against  intentional or unintentional corruption.   

Anticipated Benefits:  

• Improved access to medical care by enabling a patient to remain in his/her location while the therapist may provide  care from a distant site. 

• More efficient medical evaluation and management 

• Obtaining expertise of a distant specialist. 

Possible Risks:  

• As with any therapeutic care, there are potential risks associated with the use of telehealth. These risks include, but may not be limited to: 

• In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate decision-making by the therapist. 

• Delays in medical evaluation/treatment could occur due to deficiencies or failures of the electronic equipment. 

• In rare instances, security protocols could fail, causing a breach of privacy of personal medical information. 

• Usual risks of physical therapy interventions and exercise participation.   

By Signing this Form, I Understand the Following:  

• I understand that I may expect the anticipated benefits from the use of telehealth in my care, but that no • results can be guaranteed. 

• I understand that the laws that protect the privacy and security of health information apply to telehealth, and that  no information obtained in the use of telehealth which identifies me will be disclosed to researchers or other  entities without my authorization. 

• I understand that I have the right to withhold or withdraw my consent to the use of telehealth during my care at any  time. 

• I understand that I have the right to inspect all information obtained and recorded during a telehealth interaction  and may receive copies of this information for a reasonable fee. 

• I understand that a variety of alternative methods of medical care may be available to me, and that I may choose  one or more of these at any time. My therapist has explained the alternative to my satisfaction. 

• I understand that telehealth may involve electronic communication of my personal medical information to other  medical practitioners who may be located in other areas, including out of state. 

• I understand that it is my duty to inform my therapist of electronic interactions regarding my care that I may have  with other healthcare providers. 

• I understand that if my medical insurance coverage is not sufficient to satisfy the medical service charges in full, I may be fully responsible for payment. 

• By providing your phone number, you opt-in to receive information about Optimal Physical Therapy, including up to three  SMS messages per month. Standard messaging rates may apply. You can unsubscribe at any time by texting “STOP.”   

Patient Consent to the Use of Telehealth  

I have read and understand the information provided above regarding telehealth, have discussed it with my therapist and all my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telehealth in my therapy care. 

Thank you for your commitment to you and your health