1. I understand that my health care provider wishes me to engage in a TeleRehab consultation.
2. My health care provider has explained to me how the video conferencing technology will be used for such a consultation and will not be the same as a direct patient/health care provider visit. This is due to the fact that I will not be in the same room as my health care provider.
3. I understand there are potential risks to this technology, including interruptions, unauthorized access and technical difficulties. I understand that my health care provider or I can discontinue the TeleRehab consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.
4. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes.
5. I have had the alternatives to TeleRehab consultation explained to me, and I am choosing to participate in a TeleRehab consultation. I understand that some parts of the exam involving physical tests may be conducted by individuals at my location (family or friend) at the direction of the consulting health care provider.
6. In an emergency, local first responders will be called if needed. You will be asked your location so that we are aware of your current location if other than your home. If during your session we feel you might be experiencing any medical complications or emergency, services will be terminated, and you will be referred to an appropriate level of care.
7. I understand that billing will occur from FYZICAL Therapy and Balance CentersTherapy, LLC.
8. I have had a direct conversation with my health care provider, during which I had the opportunity to ask questions regarding this procedure. My questions have been answered and the risks, benefits, and any practical alternatives have been discussed with me in a language I understand.
9. Cancellation policy is the same for clinical or TeleRehab visits. We kindly ask that you give us 24 hours notice if you will not be able to participate in your TeleRehab visit.
10. Given the unique nature of the provision of services through TeleRehab there are special considerations including: a) consent to be photographed, recorded, or videotaped and consent to the storage of the encounter data, if applicable. If any recordings will be stored, you will be notified prior to beginning the session. Data will be kept for a minimum of 10 years, or what is required by Colorado state law; b) FYZICAL Therapy and Balance CentersTherapy and its employees and agents are not responsible for medical or other information lost during the transmission of data or technology failures.
11. Most insurances are covering TeleRehab but it is best to verify with your insurance regarding reimbursement specifics. If your insurance does not cover your TeleRehab visit, you will be billed at a rate of $25 per 15 minute increment of TeleRehab services.
12. I understand that my personal health care information is private and stored in compliance with the laws and regulations of Colorado. Our therapists have fulfilled all required regulatory and professional requirements and cultural preferences have been considered and respected during the digital interaction. By signing this form I certify: I have read or had this form read and/or explained to me. I fully understand its contents including the risks and benefits of the procedure(s I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.