NUTRITIONAL PT PHYSICAL THERAPY: Telemedicine / Telehealth Patient Consent Form


Nutritional PT offers some physical therapy consultations as a telemedicine/telehealth platform. If you elect to receive our telehealth services, you must give informed consent to agree to the following: 


  1. Our physical therapy telemedicine/telehealth consultations are provided through a HIPAA compliant and secure platform, Google Meet. By using this service, you agree to the terms of use and privacy policies of this telemedicine/telehealth platform. 

  2. The benefits to using our telemedicine/telehealth services including but not limited to not having to take the time to drive to and from appointments, minimizing time off work and from families for appointments and being able to access services at more convenient times. 

  3. We strive to provide telemedicine/telehealth services at the same standard of care of an in-person visit. However, you should know that there may be some limitations to what we can do through a telemedicine/telehealth connection compared to a face-to-face visit. For example, we will not have the use of other senses, such as touch and smell, or the ability to observe your body/condition in a 3-dimensional view. If the limitations of telemedicine/telehealth consultation will interfere with our ability to properly examine or treat you, we will let you know so you can schedule a face-face visit with us or another provider of your choice.

  4. Nutritional PT is an out-of-network provider an is not a preferred provider for insurance plans. Nutritional PT is not a Medicare provider. Nutritional PT does not bill insurance. Upon request, Nutritional PT will provide a superbill that you may submit to your insurance. Please note it is your responsibility to understand your coverage and there is no guarantee your physical therapy visit will be covered.

  5. If it would be beneficial to record our telemedicine/telehealth consultations, we will explain the reason for the need or desire to record the consultation and obtain your verbal onset in advance. If we do record the session, you may request to stop the videotaping at any time. The recording will not be stored as part of your official medical record unless we advise you that we plan to store and maintain it. If we do, it will be stored and maintained with the same privacy and security protections required by applicable state and federal laws that apply to your written medical records.

  6. There are potential risks with the use of telemedicine/telehealth technology, including but not limited to: (1) interruption of the audio/video link, (2) disconnection of the audio/video link, (3) video that may not be clear enough to meet the needs of the consultation, and (4) potential of unauthorized access to the live or stored consultation. If any of these occur, the consultation may need to be stopped and/or rescheduled. Also, we are not responsible for these or other technology problems that we are not in control of.

  7. Privacy and confidentiality. The same state and federal laws that protect your privacy and the confidentiality of your medical records apply to our telemedicine /telehealth visits if the visit is for health care services. You acknowledge by signing below that you have been given an opportunity to review our Notice of Privacy Practices and had all your questions answered. 

  8. Nutritional PT requires payment at or before the time of service for scheduled telemedicine visits.

  9. Some of the services we may provide to you through our telemedicine/telehealth platform may be considered fitness or wellness services, not physical therapy. Fitness and wellness services may not be subject to the requirements of the physical therapy practice act or other state law that apply to medical services.

  10. If we instruct you on any exercises, balance activities or other physical procedures during the telemedicine/telehealth session, you are responsible for determining whether you can safely to perform the activity without risk of falling or otherwise injuring yourself. If you do not feel safe, you must tell us. If the exercise or activity requires the assistance of a family member or caregiver (collectively “Caregivers”), you are accepting the risk of the actions of your Caregivers. We are not responsible if you fall or get injured by the actions, errors or omissions of your Caregiver. 

  11. Payment and Cancellations. You agree to pay for any scheduled telemedicine/telehealth consultation with a credit card in advance of your scheduled appointment. You must give at least 24 hours-notice in advance if you need to cancel or reschedule an appointment. If you cancel with less notice, you may be charged for that appointment.

I have read, understand and agree to all the above terms for my telemedicine/telehealth consultation. Understanding the limitations and risks associated with a telemedicine /telehealth consultation as described above, I consent to the examination and/or treatment through Nutritional PT telemedicine/telehealth service.