Cannizzaro Physical Therapy, PLC – Telehealth Consent

Cannizzaro Physical Therapy, PLC - Consent to Telehealth Treatment

Please read each section and check the box after each section that you have read and agree to the terms.

I hereby consent, of my own free will, to voluntarily engage in one or more virtual/telehealth sessions, with Cannizzaro Physical Therapy, PLC (the “Provider”) through a secure connection telephone or video conferencing system that complies with the patient confidentiality rules and other requirements of the Health Insurance Portability and Accountability Act (“HIPPA”).

I hereby consent, of my own free will, to voluntarily engage in one or more virtual/telehealth sessions, with Cannizzaro Physical Therapy, PLC (the “Provider”) through a secure connection telephone or video conferencing system that complies with the patient confidentiality rules and other requirements of the Health Insurance Portability and Accountability Act (“HIPPA”).*

I hereby consent*

I hereby consent to the evaluation and treatment of my condition by a licensed physical therapist from the Provider. I understand that the physical therapist will explain the nature and purposes of these procedures, evaluation, and course of treatment.

I hereby consent to the evaluation and treatment of my condition by a licensed physical therapist from the Provider. I understand that the physical therapist will explain the nature and purposes of these procedures, evaluation, and course of treatment.*

I hereby consent*

I hereby agree that any licensed physical therapist, technician or other employee of the Provider may participate in and/or observe my telehealth consultation or session, but that no other person may be present, participate in or observe such session without my express consent, which consent may be given orally at the beginning of a telehealth session.

I hereby agree that any licensed physical therapist, technician or other employee of the Provider may participate in and/or observe my telehealth consultation or session, but that no other person may be present, participate in or observe such session without my express consent, which consent may be given orally at the beginning of a telehealth session.*

I hereby agree*

I understand and agree that under Vermont law, neither the Provider nor I, nor any other person present for a telehealth session may record such session.

I understand and agree that under Vermont law, neither the Provider nor I, nor any other person present for a telehealth session may record such session.*

I understand & agree*

I understand that recommendations will be made by my therapist, based on the findings in this session, for improvement of my pain and overall wellness. I understand that I may be directed through specific activities, exercises and/or movements as instructed by my therapist. I am aware that my physical therapist will inform me of expected benefits and complications, and any discomforts, and risk that may arise, as well as alternatives to the proposed treatment and the risk and consequences of no treatment.

I understand that recommendations will be made by my therapist, based on the findings in this session, for improvement of my pain and overall wellness. I understand that I may be directed through specific activities, exercises and/or movements as instructed by my therapist. I am aware that my physical therapist will inform me of expected benefits and complications, and any discomforts, and risk that may arise, as well as alternatives to the proposed treatment and the risk and consequences of no treatment.*

I understand & agree*

I understand that virtual/telehealth physical therapy sessions may not provide all of the same benefits as in-person sessions, due, in part, to the fact that the physical therapist will not be able to physically assess my range of motion or detect areas of resistance or tension to the same degree as may be possible in person. However, I also understand and agree that when and to the extent that it is not practical or possible to have an in-person session, a telehealth session may still provide benefits over no physical therapy session of any kind.

I understand that virtual/telehealth physical therapy sessions may not provide all of the same benefits as in-person sessions, due, in part, to the fact that the physical therapist will not be able to physically assess my range of motion or detect areas of resistance or tension to the same degree as may be possible in person. However, I also understand and agree that when and to the extent that it is not practical or possible to have an in-person session, a telehealth session may still provide benefits over no physical therapy session of any kind.*

I understand & agree*

I have been informed and understand that during my participation in any sessions, I will be responsible for honestly reporting any symptoms that I may experience, such as pain, fatigue, shortness of breath, pain or ANY other findings.

I have been informed and understand that during my participation in any sessions, I will be responsible for honestly reporting any symptoms that I may experience, such as pain, fatigue, shortness of breath, pain or ANY other findings.*

I understand & agree*

I know that it is my right to stop any activity at any time, during any session.

I know that it is my right to stop any activity at any time, during any session.*

I understand & agree*

I understand that my therapist will make every effort to address my symptoms, functional deficits (if any) and concerns, and that the goal is for total alleviation of symptoms and/ or improvement of function. Even with the best program, I understand there is a possibility that I may not notice changes or improvements.

I understand that my therapist will make every effort to address my symptoms, functional deficits (if any) and concerns, and that the goal is for total alleviation of symptoms and/ or improvement of function. Even with the best program, I understand there is a possibility that I may not notice changes or improvements.*

I understand & agree*

I recognize that these sessions may allow me to learn ways to move better, feel better and teach me techniques and skills that I can utilize independently on a daily basis to improve my quality of life.

I recognize that these sessions may allow me to learn ways to move better, feel better and teach me techniques and skills that I can utilize independently on a daily basis to improve my quality of life.*

I understand & agree*

I am aware that addressing my symptoms or diagnosis may take a few sessions and that I am required to closely follow all provided instruction to ensure improvements within at least 4-6 sessions (if not sooner).

I am aware that addressing my symptoms or diagnosis may take a few sessions and that I am required to closely follow all provided instruction to ensure improvements within at least 4-6 sessions (if not sooner).*

I understand & agree*

I understand that the number of sessions will vary based on the primary complaints and symptoms and that this reference serves as an average and not a definite number.

I understand that the number of sessions will vary based on the primary complaints and symptoms and that this reference serves as an average and not a definite number.*

I understand & agree*

I understand that I am 100% responsible for payment. Although the Provider may agree to submit a claim for payment to any insurer I request, I understand and agree that such a submission is not a guarantee of insurer payment, and that I shall remain responsible for any applicable co-pays, co-insurance, and/or amounts not paid by my insurer.

I understand that I am 100% responsible for payment. Although the Provider may agree to submit a claim for payment to any insurer I request, I understand and agree that such a submission is not a guarantee of insurer payment, and that I shall remain responsible for any applicable co-pays, co-insurance, and/or amounts not paid by my insurer.*

I understand & agree*

In taking part in these sessions, via phone or video platform, I acknowledge that I am fully responsible for any and all risks, injuries, or damages, known or unknown, which might occur as a result of my participation, including but not limited to bodily harm (up to and including death) to myself or others and personal property damage.

In taking part in these sessions, via phone or video platform, I acknowledge that I am fully responsible for any and all risks, injuries, or damages, known or unknown, which might occur as a result of my participation, including but not limited to bodily harm (up to and including death) to myself or others and personal property damage.*

I understand & agree*

I understand and agree that this Consent shall be governed by and construed in accordance with the laws of the State of Vermont, without giving effect to principles of conflict of laws that would require the application of any other law.

I understand and agree that this Consent shall be governed by and construed in accordance with the laws of the State of Vermont, without giving effect to principles of conflict of laws that would require the application of any other law.*

I understand & agree*

By signing below, I hereby INDEMNIFY AND AGREE TO HOLD HARMLESS AND WAIVE THE RIGHT TO FILE ANY CLAIM against Cannizzaro Physical Therapy, PLC, its owners, officers, employees, and instructors from any claim, demand, cause of action of any kind resulting from or related to my participation in the online/telehealth sessions except to the extent that such a waiver, indemnification, and release is not permitted by law.

Your Full Name*

Electronic Signature of Patient (or Guardian)* By typing your name in the space below you are providing an "electronic signature" and it indicates your approval of the information contained in this electronic form.

Date*

Cannizzaro Physical Therapy, PLC - Telehealth Consent

Cannizzaro Physical Therapy, PLC - Consent to Telehealth Treatment