Informed Consent for Physical Therapy Virtual Consultation With Premier Physical Therapy of the Upstate
The purpose of this form is to obtain your consent to participate in a telehealth consultation for outpatient therapy services with a licensed therapist from TherapyNow by Premier Physical Therapy of the Upstate.
The Virtual Consultation Process
Virtual Consultations with Premier Physical Therapy of the Upstate are designed to allow the physical therapist to get enough information about your pain or injury through questions and movement analysis to give you a professional opinion on your potential to benefit from physical therapy or another healthcare related service. Virtual Consultations do not start the physical therapy process – consultations only give guidance on what to expect from pursuing further care or from not pursuing further care.
You have the right to decline any portion of the virtual consultation at any time. Your physical therapist stands ready to answer any questions you may have regarding the consultation itself or regarding the professional opinion or suggestions offered by the physical therapist as a result of the consultation.
Fees
One virtual physical therapy consultation typically lasts no more than 15 minutes. The rate is $30.00.
Medical Information and Records
All existing laws regarding your access to medical information and copies of your medical records apply to this telehealth visit. Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient information.
Confidentiality
Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with a telehealth visit, and all existing confidentiality protections apply to information disclosed during this telehealth visit.
Agreement
I hereby authorize and give consent to Premier Physical Therapy of the Upstate to provide a virtual consultation with me. I am giving this consent with the understanding that any suggestion given by the physical therapist is an opinion based on the information received and that other healthcare alternatives may be available that can help you.
