Family Physical Therapy Services, Inc Informed Consent

  1. I understand that I am participating in a telemedicine consultation.
  2. It has been explained to me how the telecommunication technology will be used to affect such a consultation and will not be the same as a direct patient/health care provider visit due to the fact that I will not be in the same room or an in-person encounter.
  3. I understand the limitations that Telemedicine services present compared to an in-person encounter, particularly the inability to perform hands-on examination, assessment and treatment, and I understand the risks, benefits and consequences to not seeking immediate medical attention in the event of an emergency.
  4. In an emergent consultation, I understand that the responsibility of the telemedicine consulting specialist is to advise me on seeking immediate medical attention and that the specialist’s responsibility will conclude upon the termination of the telecommunication connection.
  5. I understand that every attempt is being made to abide be the Health Insurance Portability and Accountability Act of 1996 (HIPAA), but there are potential risks to this technology, including interruptions, unauthorized access and technical difficulties. I understand that the consultant or I can discontinue the telemedicine consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.
  6. I understand that my healthcare information may be shared with other individuals to effect an acceptable outcome. Others may also be present during the consultation other than the provider in order to operate the telecommunication equipment. The above mentioned people will all maintain confidentiality of the information obtained per HIPAA guidelines. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/physical examination that are personally sensitive to me; (2) ask non‐medical personnel to leave the room: and or (3) terminate the consultation at any time.
  7. I understand the alternatives to a telemedicine consultation, and in choosing to participate in a telemedicine consultation, I understand that some parts of the exam involving physical tests may be conducted by individuals at my location at the direction of the consulting health care specialist.
  8. I understand that I will be responsible for all billing as outlined on the website.
  9. I understand that the information provided is not to be construed as a medical diagnosis and that telemedicine is not a substitute for direct person to person care and that it is my responsibility to seek immediate medical attention in the event of an emergency.

I certify:

  • That I have read or had this form read and/or had this form explained to me
  • That I fully understand its contents including the risks and benefits of the procedure(s).
  • That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.