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Telehealth Form
  • DEFINITION: "Telehealth" -- "telehealth is the use of electronic information and telecommunications technologies to support long-distance clinical healthcare, patient and professional health-related education, public health and health administration." (The Joint Commission July 2014) Telehealth is not a separate medical specialty. It is a delivery tool or system.
  • 1. I do hereby give my consent to the performance of REHAB AT WORK of Telehealth Physical Therapy or Telehealth Occupational Therapy (hereinafter referred to as "Telehealth Therapy"). I understand that Telehealth Therapy differs from in-Clinic Physical Therapy or In-Clinic Occupational Therapy (hereinafter referred to as "In-Clinic Therapy") as it is provided remotely by video and audio conferencing and is not considered a direct substitute for In-Clinic Therapy services. I understand that Telehealth Therapy does not provide the same access to treatment modalities and equipment or hands-on evaluation and treatment as In-Clinic Therapy and therefore is generally recommended as a temporary treatment course in the interim where I am not able to attend In-Clinic Therapy or in situations where In-Clinic Therapy is not feasible for me. I understand that I am voluntarily participating in Telehealth Therapy using telehealth technology rather than an in-person, face to face, visit.
  • 2. I understand that this Telehealth Therapy will not be the same as in-person, face to face, patient/health care provider visit due to the face that I will not be in the same room as my health care provider. My health care provider has explained to me how the video conferencing technology will be used in connection with the consultation/treatment.
  • 3. I understand there are potential risks when using this technology, including interruptions, possible unauthorized access, and technical problems, e.g., equipment failure. I understand that my health care provider(s) or I can discontinue the telehealth consult/visit ay any time.
  • 4. I understand that use of Telehealth Therapy technology presents additional privacy and security risks over In-Clinic Therapy by inherent use of the technology itself. I understand that the United States Department of Health and Human Services has provided a "Notification of Enforcement Discretion for Telehealth Remote Communications During the COVID-19 Nationwide Pubic Health Emergency" available to view at this website: https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notifcations-enforcement-discretion-telehealth/index.html. Therefore during the COVID-19 Nationwide Public Health Emergency,, REHAB AT WORK may use Telehealth Therapy technology which may present additional privacy and security risks of my Protected Health Information over HIPAA Rules. I had these additional risks explained to me and freely and voluntarily assume these risks for the provision of Telehealth Therapy by REHAB AT WORK.
  • 5. I understand that there are certain risks associated with Telehealth Therapy including, but not limited to: pain, tightness, tenderness, soreness, rashes, burns, slip and fall, dislocation, bone fracture, general discomfort, re-injury and cardiopulmonary signs, such as elevated heart rate, labored breathing, and excessive sweating or light-headedness. I freely and voluntarily assume these risks. I understand that there are possible benefits associated with Telehealth Therapy including greater mobility, recovery, less pain, improved performance level, more function, higher endurance, and better ability to perform activities of daily living including work tasks. However, I understand that there is no certainty that I will achieve these benefits and no guarantee has been made for me regarding the outcome of Telehealth Therapy.
  • 6. I understand that there are reasonable alternative(s) to Telehealth Therapy including but not limited to In-Clinic Therapy, chiropractic, acupuncture, massage, and fitness training.
  • 7. I have been given an opportunity to ask questions and all of my questions have been answered to my satisfaction.
  • 8. I agree to the performance of Telehealth Therapy by a licensed staff member at REHAB AT WORK and I understand that he/she will be assisted by other health care professionals such as others as he/she considers necessary in my care. I agree to their participation in my care.
  • 9. I take personal responsibility to report or communicate to the therapist any symptoms or concerns that I have as soon as possible. I will take responsibility to follow and conduct myself consistent with the instructions and directions of the therapist including, but not limited to: giving my best effort in participation in Telehealth Therapy, performing home exercise programs as instructed, and wearing assistive devices as instructed. I understand that I retain the right to decide whether I will continue, modify, stop, or decline to perform any activity in part or in whole and this will be documented as such.
  • 10. I have read the information provided above or it has been read to me. I have been given a copy of this form upon request.