Location of Patient: Patent MUST be in the state of Oklahoma to receive tele therapy services.
Provided by a Can Do Kids Therapist with the physical Office Location: 1073 N Bryant, Suite 100, Edmond OK. 73034
I understand that tele therapy is the use of electronic information and communication technologies by a healthcare provider to deliver services to an individual when he/she is located at a different site other than the provider; and hereby consent to Can Do Kids therapist(s) to provide my child services via telemedicine.
I understand that the laws that protect privacy and the confidentiality of medical information also apply to tele therapy. As always, your insurance carrier will have access to your medical records for quality review/audit.
I understand that the therapist will limit exposure of patient to other’s at their current location. Caregivers, the client, and other family members may be present during tele therapy session.
I understand that tele therapy video information will not be stored, or forwarded to anyone else.
I understand that written documentation will be kept for records per usual.
I understand that I will be responsible for any copayments or co-insurances that apply to my telemedicine.
I understand that I have the right to withhold or withdraw my consent to the use of tele therapy in the course of my care at any time without affecting my right to future care or treatment.
I may revoke my consent orally or in writing at any time by contacting Can Do Kids at 405-513-8186.
As long as this consent is in force (has not been revoked) Can Do Kids may provide therapy services to me via tele therapy without the need for me to sign another consent form.