Informed Consent for Telehealth Services

Nature Of Telehealth Consultation

Telehealth involves the use of audio, video, or other electronic communication to enable a health care provider to interact with a patient and provide medical consultation, therapy, or treatment from a remote location. Audio-conferencing and/or video-conferencing technology will be used to facilitate the telehealth session between a therapist and patient located in two different locations. The session may be recorded for quality review, operations, training, research, and safety purposes in accordance with applicable law.

By indicating my acceptance below, I acknowledge that a telehealth consultation will not be the same as an in-person visit with a healthcare provider due to the fact that I will not be in the same room as my therapist and, as a result, may carry certain risks.

Physical Therapy

The purpose of physical therapy is to treat disease, injury and disability by examination, evaluation and intervention by use of rehabilitative procedures, mobilization, manual techniques, exercises, and physical agents to aid the patient in achieving their maximum potential, within their capabilities, and to accelerate functional recovery. By indicating my acceptance below, I acknowledge that due to the nature of digital healthcare and telehealth services that I may be limited in the availability of some of the above services. However, I also understand that my physical therapist will thoroughly explain to me the plan before it is performed.

By indicating my acceptance below, I acknowledge that my physical therapist provides a differential diagnosis for a condition but cannot give me a medical diagnosis, and physical therapy is not a substitute for a medical diagnosis by a physician. I recognize that my physical therapist is trained to identify functional deficits and movement disorders and provide treatment in the case of SimpleTherapy, Inc. I also understand that I may be receiving therapy care from my physical therapist without a medical diagnosis. I agree to provide my therapist with accurate and complete information regarding my condition, medical history, and medical care to assist my therapist in rendering appropriate care.

Risks, Benefits And Alternatives

I understand that there are risks and benefits to telehealth physical therapy. The benefits of telehealth include the ability to efficiently access a healthcare provider from home or other location. Potential risks of the SimpleTherapy, Inc. telehealth platform include:

• Inability to conduct hands-on examination and treatment,
• Technical problems such as unclear video, loss of sound, or connection interruption that may require a session to be rescheduled or require a follow- up face-to-face consultation,
• In rare circumstances, security measures could fail causing a potential breach of personal medical information, or
• limited ability to respond to emergencies.

I understand that I, or my SimpleTherapy, Inc. therapist, may discontinue or reschedule a telehealth consultation if the video quality or audio connection is not adequate for the situation. I further agree not to not hold SimpleTherapy responsible for lost information due to technological failures.

Confidentiality

Personal information that SimpleTherapy, Inc. uses or maintains, including information obtained during telehealth sessions, is confidential and subject to laws that protect health information, including the Health Insurance Portability and Accountability Act of 1996 and its implementing regulations (HIPAA).

I understand, agree, and consent to SimpleTherapy, Inc. obtaining, using, storing, and disclosing, as appropriate, information about me, including my image, as necessary to provide telehealth services. I understand that my healthcare information may be shared confidentiality with my care team and other authorized individuals when required for my treatment, healthcare operations, and billing/payment purposes. By indicating my acceptance below, I authorize SimpleTherapy to share my health information to individuals permitted to receive such information under applicable state and federal law.

Billing And Payment

I understand that SimpleTherapy, Inc. may bill my health plan and/or insurance company for services provided. By indicating my acceptance below, I authorize, assign, and request payment of authorized insurance benefits to SimpleTherapy, Inc. for covered services. As a courtesy, SimpleTherapy, Inc. will assist with filing insurance claims as appropriate. I acknowledge that I am responsible for notifying SimpleTherapy, Inc. of any changes to my insurance carrier or insurance coverage. All efforts relating to the collection of applicable insurance benefits are for convenience and do not represent a guarantee of collections or credit to the account until payment is received. I agree to assist SimpleTherapy, Inc. in filing insurance claims, as requested.

I understand that I am responsible for payment of any deductible, coinsurance, or co-pay amounts as stipulated by my insurance plan, as well as any services which are not covered by my insurance plan. I understand that I am ultimately responsible for payment of all services not covered by my insurance. I agree to pay all collection costs, late fees, attorneys' fees, and court costs associated with amounts owed by me for services rendered by SimpleTherapy, Inc. regardless of whether or not a suit is actually filed. Delinquent accounts shall bear interest on the unpaid amount at the lower of the rate of 10% per annum or such interest rates as allowed by applicable law.

By indicating my acceptance below, I agree and provide express written consent (in order for SimpleTherapy, Inc. to service the account or to collect amounts owed) for SimpleTherapy, Inc. and its agents, contractors, successors, and assigns, including any service providers, collection agencies, or other third parties acting on its behalf, to: (A) contact me at any telephone number (including wireless numbers, pager numbers, fax numbers, virtual or internet numbers, or any other numbers that may result in use charges), e-mail address, or other unique electronic identifier that is associated with the account or that is provided to SimpleTherapy, Inc. at any time, now or in the future; (B) contact me using any current or future means of communication, including pre-recorded/artificial voice messages, automatic or predictive dialing devices, text message, or other forms of electronic messages, as applicable, in connection with any communications regarding the account, including collection of amounts owed; and (C) leave answering machine and voicemail messages, in compliance with applicable laws, for any reason, now or in the future, including collection of amounts owed on the account. If I do not want to continue receiving communications, I must: (i) provide SimpleTherapy, Inc. with written notice revoking this consent; (ii) in such notice, include my name, address, and last four digits of the account number; (iii) advise whether communications should cease via mail, telephone, e-mail, text, or cease in all forms; (iv) if communications should cease via telephone and/or e-mail, provide the specific number(s) and or e-mail address(es) at which the communications should cease; and (v) send this written notice to SimpleTherapy, Inc.

No Show And Late Cancel Policy

Once an appointment is scheduled, the patient will be expected to pay for the appointment unless 24 hours advance notice of cancellation is provided. Simple Therapy will charge a late cancellation fee of $65 for late cancellations and appointment no shows. If employer paid therapy and physical therapy sessions are being used, late cancellations and no-show appointments will be deducted from the total session count. Exceptions may be made, on a case-by-case basis, if a patient's provider agrees that the patient was unable to attend due to circumstances beyond the patient's control, such as unexpected illness. If an appointment is cancelled with less than 24-hours' notice or there is a no-show, SimpleTherapy, Inc. will contact the patient to set up another appointment. Three repeated missed appointments or no shows may be grounds for termination of treatment.

Emergencies

In an emergency, to ensure the safety of myself or others, I understand that the responsibility of the telehealth provider may include contacting my local practitioner, emergency services, or law enforcement, including 911 services. I understand that telehealth should not be used for emergency communications.

State Specific Consents

The following consents apply to users accessing the DLMD website for the purposes of participating in a telehealth consultation as required by the states listed below:

California: I understand that I am receiving direct therapy treatment services and may continue to receive direct physical therapy treatment services for a period of up to 45 calendar days or 12 visits, whichever occurs first. My physical therapist may continue providing me with physical therapy treatment services after this period only after receiving a dated signature on the physical therapist’s plan of care indicating approval of the physical therapist’s plan of care from a physician, surgeon, or podiatrist. I also understand that an in-person patient examination and evaluation was conducted by the physician and surgeon or podiatrist.

Georgia: I understand that I am receiving physical therapy through direct access. I understand a physical therapy diagnosis is not a medical diagnosis by a physician or based on radiological imaging and that such services might not be covered by my health plan or insurer.

New York: I understand that I am receiving physical therapy through direct access. I understand a physical therapy diagnosis is not a medical diagnosis by a physician or based on radiological imaging and that such services might not be covered by my health plan or insurer. I also understand that these services could potentially be covered by my health plan or insurer if there is a referral.

Questions

I have had the opportunity to ask my provider questions about telehealth prior to receiving the services to better understand the risks, benefits and any practical alternatives described in this consent.

Acknowledgment:

By indicating my acceptance below, I acknowledge as follows:

• I am of the age of majority and legally authorized to consent to telehealth therapy services.
• I have read this form and fully understand its contents including the risks and benefits of the telehealth therapy services.
• I may ask my provider questions regarding the benefits and risks of telehealth therapy and will ensure those questions are answered to my satisfaction prior to receiving services.
• I understand and accept the nature, purpose, side effects, risks, and benefits of the services being provided.
• I understand that healthcare is not an exact science, and acknowledge that no promises or guarantees have been made regarding the services to be rendered.
• I hereby give consent to telehealth therapy services as an acceptable form of delivering healthcare services to me and that this consent will cover any and all of my sessions using telehealth.
• I understand and agree that I am signing this consent electronically by checking the box in the registration process.