HIPAA Notice

INFORMED CONSENT FOR TELEHEALTH PHYSICAL THERAPY SERVICES

1. Introduction and Nature of Telehealth

I hereby consent to engage in telehealth-based physical therapy with Unlock Performance and Rehab. I understand that "telehealth" includes the practice of physical therapy, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, or data communications.

I understand that with telehealth, I will not be in the same room as my physical therapist. The services provided will be consistent with the Washington State Standard of Care (WAC 246-915-187), meaning my therapist will exercise the same degree of skill and care as would be provided in an in-person appointment.

2. Technology and Privacy (HIPAA Compliance)

  • Secure Platform: I understand that my physical therapist will use a HIPAA-compliant video conferencing platform (e.g., Doxy.me, Zoom for Healthcare, etc) that encrypts the connection to protect my privacy.

  • Confidentiality: I understand that the laws that protect the confidentiality of my medical information (including HIPAA and Washington State privacy laws) also apply to telehealth. No information or images will be disclosed to other entities without my consent, except as required by law.

  • Recording: I understand that our sessions will not be recorded by the provider without my explicit verbal or written consent. I agree not to record the session myself without the provider's permission.

  • Patient Environment: I agree to participate in the telehealth session from a private, quiet, and well-lit setting where I can speak freely without being overheard to ensure my own privacy.

3. Potential Risks and Limitations

I understand there are risks and limitations unique to telehealth, including but not limited to:

  • Technology Failure: The video or audio connection may be interrupted or distorted by technical failures, which could delay or disrupt care.

  • Limited Assessment: The physical therapist cannot perform hands-on manual testing (such as joint mobilization or specific palpation). The therapist will rely on visual observation and my self-reporting to assess my condition. If the therapist believes my condition requires a hands-on physical exam for safety or diagnosis, they may require me to schedule an in-person visit or refer me to a local provider.

  • Security Risks: Despite reasonable security measures, there is a remote risk that electronic communications could be intercepted or accessed by unauthorized persons.

4. Emergency Plan

  • Location Confirmation: I agree to confirm my current physical location (address) at the beginning of each session.

  • Emergency Protocol: In the event of a medical emergency during the session, I understand my therapist will call 911 or the local emergency services for my location.

  • Disconnection: If we are disconnected and cannot reconnect via video, I consent to my therapist contacting me by phone at the number I have provided on my intake forms.

5. Patient Rights

  • I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment.

  • I have the right to inspect all medical information transmitted during a telehealth consultation and may receive copies of this information for a reasonable fee.

6. Financial Agreement (Cash-Pay Only)

I understand and agree to the following financial terms:

  • Full Responsibility: I understand that Unlock Performance and Rehab is a 100% cash-based practice. I am fully responsible for the total cost of all services rendered.

  • No Insurance Billing: I acknowledge that Unlock Performance and Rehab does not contract with any insurance companies (including commercial payers, Medicare, or Medicaid) and will not bill my insurance carrier for services provided.

  • No Superbills: I understand that Unlock Performance and Rehab will NOT provide "Superbills" or itemized receipts for the purpose of insurance reimbursement. I acknowledge that I cannot submit claims to my insurance company for these services and that the cost of care is an out-of-pocket expense that will not apply to my insurance deductible.

  • Medicare: I understand that Unlock Performance and Rehab is not enrolled with Medicare. Therefore, Medicare cannot be billed for these services by either the therapist or the patient. I strictly agree not to submit claims to Medicare for any services provided by Unlock Performance and Rehab.

  • Payment: I authorize Unlock Performance and Rehab to charge my credit card on file for the full rate of the session at the time of service, including any late cancellation fees as outlined in the cancellation policy.

7. Acknowledgement

By signing below, I acknowledge that:

  • I have read and understand the information provided above regarding telehealth.

  • I understand the financial policy and that I will not receive documentation to submit to insurance.

  • I have had the opportunity to ask questions, and all my questions have been answered to my satisfaction.

  • I hereby give my informed consent for the use of telehealth in my physical therapy care with Unlock Performance and Rehab.