PURPOSE. The purpose of this form is to obtain your consent for a telehealth interaction with a physical therapist. 

NATURE OF TELEHEALTH CONSULTATION. 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 other health professionals using interactive video, audio and telecommunications technology. Additionally, a physical examination of you may take place and video, audio, and/or photo recordings may be taken. 

RISKS, BENEFITS AND ALTERNATIVES. The benefits of telehealth include having access to physical therapy services and additional medical information and education without having to travel outside of your home. A potential risk of telehealth is that because of your specific medical condition, or due to technical problems, a face-to-face consultation still may be necessary after the telehealth appointment. Additionally, in rare circumstances, security protocols could fail causing a breach of patient privacy. The alternative to telehealth consultation is a face-to-face visit with a physical therapist. 

MEDICAL INFORMATION AND RECORDS. All laws concerning patient access to medical records and copies of medical records apply to telehealth. Dissemination of any patient identifiable images or information from the telehealth consultation to researchers or other entities shall not occur without your consent. 

CONFIDENTIALITY. All existing confidentiality protections under federal and state law apply to information used or disclosed during your telehealth consultation.

RIGHTS. You may withhold or withdraw your consent to a telehealth consultation at any time before and/or during the consult without affecting your right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled.