Online PT Telehealth Consent

Telehealth uses the Internet to provide remote health care. This care may be given by doctors, nurses, mental health professionals, or health educators. In this case, my provider will communicate with me remotely through doxy.me, a web-based audio-video platform. Doxy.me hosts the software but does not offer medical advice.

Telehealth Appointments may be used for diagnosis, follow-up care, treatment, testing, or consultation as needed by me or my provider.

I Understand That During A Telehealth Appointment:

  • Details of my medical history and personal health information may be discussed with me and/or other health professionals  
  • Audio, video, or photo recordings containing medical details may be transmitted via secure channels and those details may become part of my permanent medical record  
  • All confidentiality protections granted to me by various state and federal laws also apply to my care during this appointment  
  • Industry-standard network and software security protocols are in place that protect the privacy of the communication and safeguard my transmitted information against eavesdropping and corruption  
  • There may be security and privacy risks associated with Internet-based communications  
  • There are benefits and limitations when compared to a traditional in-person visit due to the fact that I will not be in the same room as my healthcare provider 
  • Either my Healthcare Provider or I can discontinue the Telehealth Appointment if either of us feels that the information obtained through remote communications is not adequate for diagnostic decision-making or for providing the care I desire  
  • In addition to my Healthcare Provider named above, I will be informed of any other person(s) who may be present during the appointment and have the right to have them leave the viewing and listening area  
  • To maintain my privacy, I need to ensure that my viewing and listening area is limited to myself and any other person that has a need to participate during the virtual appointment  
  • Due to the limitations of telehealth that are out of my control (such as an unreliable internet connection), I will call local authorities (9-1-1) to assist me with a medical emergency  
  • I have the right to omit or withhold specific details of my medical history/physical examination that are personally sensitive  
  • My Healthcare Provider may advise me to seek immediate treatment or determine that there is a medical emergency and, as such, local authorities may be given my personal details to assist me  
  • The communication is privileged and confidential, and I will not record the audio or video without first seeking the permission of my Healthcare Provider

By Consenting To This Telehealth Appointment:

  • I desire to engage in remote audio-visual communication with my Healthcare Provider  
  • I understand the risks and benefits of using Internet-based communications and that no results can be guaranteed  
  • I acknowledge that if the Healthcare Provider believes that remote communication is insufficient for treatment, consultation, or evaluation, then I will be offered alternate services or options  
  • I understand that I may be responsible for co-payments, deductibles, or other charges from my Healthcare Provider, and additional charges may occur for services related to this appointment  
  • I understand that some parts of the exam involving physical tests may be conducted by individuals at my location, or at a testing facility, at the direction of the Healthcare Provider  
  • I have the ability to ask direct questions to my Healthcare Provider about this appointment, including details about the Healthcare Provider's privacy policy  
  • If my questions are not answered to my satisfaction, I have the right to terminate the appointment  
  • I am at least 18 years of age