AUTHORIZED CONSENT FORM
Telehealth physical therapy involves the use of electronic communications to enable healthcare providers
at different locations to share individual patient clinical information and deliver physical therapy services
for the purpose of improving patient care. Telehealth services offered by Wheaton Physical Therapy
Clinic PLLC (“WPTC”) may also include chart review, appointment scheduling, health information
sharing, and non-clinical services, such as patient education. The information you provide may be used
for diagnosis, therapy, follow-up and/or patient education, and may include any combination of the
following:
1. health records and test results;
2. images and asynchronous communications;
3. live two-way audio-video;
4. interactive audio with store and forward; and
5. output data from medical devices and sound and video files.
The electronic communication systems we use will incorporate network and software security protocols
to protect the confidentiality of patient identification and imaging data and will include measures to
safeguard the data and to ensure its integrity against intentional or unintentional corruption.
Our physical therapists are an addition to, and not a replacement for, your primary care physician.
Responsibility for your overall medical care remains with your local primary care physician, if you have
one, and we strongly encourage you to locate one if you do not.
Potential benefits include (but are not limited to):
• Improved access to care by enabling you to remain in your home for physical therapy sessions.
• More efficient care evaluation and management.
Potential risks include (but are not limited to):
• Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment
and technologies.
• We may determine that the transmitted information is of inadequate quality, thus necessitating a
rescheduled telehealth consult or an in-person appointment with your physical therapist or
primary care physician.
• Security protocols could fail, causing a breach of privacy of personal medical information.
• A lack of access to complete medical records may result in adverse drug interactions or allergic
reactions or other judgment errors, although we do not issue prescriptions.
Informed Consent
By signing this agreement, I hereby acknowledge that I consent to, understand and agree to the following:
1. I consent to receiving WPTC’s services via telehealth technologies, which may include
communication via video chat, video message, recorded exercise instruction, telephone, and
email. I understand that WPTC offers telehealth-based physical therapy services, but that these
services do not replace the relationship between me and my primary care physician. I also
understand it is WPTC’s decision as to whether my specific physical therapy and treatment needs
are appropriate for a telehealth physical therapy session.
2. I understand that federal and state law requires health care providers to protect the privacy and the
security of health information. I understand that WPTC will take steps to make sure that my
health information is not seen by anyone who should not see it. I understand that telehealth may
involve electronic communication of my personal medical information to other health
practitioners who may be located in other areas, including out of state.
3. I understand there is a risk of technical failures during the telehealth physical therapy session or
consultation beyond the control of WPTC. I agree to hold harmless WPTC for delays in
evaluation or for information lost due to such technical failures. I understand that if a telehealth
physical therapy session or consultation is terminated due to technical failures, I am still
responsible for payment for such session or consultation.
4. I understand that 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
understand that I may suspend or terminate use of the telehealth services at any time for any
reason or for no reason.
5. I understand that if I am experiencing a medical emergency, I should dial 9-1-1 immediately and
that WPTC is not able to connect me directly to any local emergency services.
6. I understand that alternatives to telehealth services, such as in-person services, may be available
to me, and in choosing to participate in a telehealth consultation, I understand that some parts of
the services involving tests may be conducted by individuals at my location, or at a testing
facility, at the direction of WPTC (e.g. labs or bloodwork).
7. I understand that no potential benefits or results can be guaranteed or assured.
8. I understand that my healthcare information may be shared with other individuals for scheduling
and billing purposes. Persons may be present during the consultation other than the physical
therapist in order to operate the telehealth technologies. I further understand that I will be
informed of their presence in the consultation and thus will have the right to request the
following:
a. omit specific details of my medical history/examination that are personally sensitive to
me;
b. ask nonmedical personnel to leave the telehealth physical therapy session or consultation;
and/or
c. terminate the telehealth physical therapy session or consultation at any time.
9. I understand that I will not be prescribed any narcotics for pain, nor is there any guarantee that I
will be given a prescription at all.
10. I understand that if I participate in a telehealth physical therapy session or consultation, I have the
right to request a copy of my medical records, which will be provided to me at reasonable cost of
preparation, shipping and delivery.
11. I will not audio or video record the telehealth physical therapy session or consultation, although I
may take still photographs to document clinical pathology.
12. I am responsible for ensuring that (i) I am participating in my telehealth physical therapy session
or consultation in a safe environment and (ii) I am wearing appropriate clothing and have the
appropriate equipment to exercise/perform during my telehealth physical therapy session or
consultation.
13. I understand that threats or abusive language will not be tolerated and may result in termination of
the telehealth physical therapy session or consultation. I understand that in such a situation,
WPTC may provide me with the contact information for other telehealth providers. I understand
that if a telehealth physical therapy session or consultation is terminated under these
circumstances, I am still responsible for payment for such service.
14. I agree to be recorded and photographed during my telehealth physical therapy session or
consultation.
15. No third party health insurance will be billed for payment for my telehealth physical therapy
sessions or consultations and I am solely responsible for all such payments. Payment will be
accepted via electronic form credit card, Apple Pay, or Google Pay. Invoices for services rendered are due
upon receipt.
16. I fully understand and acknowledge that (i) the activities in which I will engage as part of the
treatment provided by WPTC, and the physical therapy activities and equipment I may use as a
part of that treatment, have inherent risks, dangers, and hazards; (ii) my participation in such
treatment and activities and/or use of such equipment may result in injury or illness NJ including,
but not limited to bodily injury, disease, strains, fractures, partial and/or total paralysis, other
ailments that could cause serious disability, and death; (iii) there is a risk that my health condition
may worsen or may not be resolved despite my telehealth physical therapy sessions or
consultations; and (iv) these risks and dangers may be caused by the negligence of the agents,
representatives or employees of WPTC, the negligence of the participants, the negligence of
others, accidents, breaches of contract, or other causes. By my participation in these activities
and my use of equipment, I hereby assume all risks and dangers and all responsibility for any
losses and/or damages whether caused in whole or in part by the negligence or the conduct of the
agents, representatives or employees of WPTC, or by any other person or entity. I, on behalf of
myself, my agents, my personal representatives and my successors, hereby release, waive,
discharge, hold harmless, defend, and indemnify WPTC and its agents, representatives,
employees, and assigns from any and all claims, actions or losses for bodily injury, property
damage, wrongful death, loss of services or otherwise which may arise out of my use of any
equipment or participation in these activities. I specifically understand that I am releasing,
discharging, and waiving any claims or actions that I may have presently or in the future for the
negligent acts or other conduct by the agents, representatives or employees of WPTC.
17. Any controversy or claim arising out of or relating to this agreement, or the breach thereof, shall
be settled by arbitration administered by the American Arbitration Association under its
Commercial Arbitration Rules. Illinois law shall apply. Judgment on the award rendered by the
arbitrator may be entered in any court having jurisdiction thereof.
Patient Consent
I have read this document carefully and understand the risks and benefits of the telehealth consultation
and have had my questions regarding the procedure explained and I hereby give my informed consent to
participate in a telehealth consultation under the terms described herein. I hereby state that I have read,
understood, and agree to the terms of this document.