Consent to Virtual Physical Therapy Services

DO NOT USE THE SERVICES IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. In an emergency or potential emergency situation, please call 911, contact your doctor, go to the nearest emergency room, or urgent care center, or contact your local crisis center.

Please carefully review this Consent to Virtual Physical Therapy Services, which is intended to inform you of what you can expect in connection with the physical therapy services provided to you via telehealth technologies by RightMove Physical Therapy Services PLLC (domiciled in Connecticut) and RightMove Physical Therapy Services PLLC (domiciled in New York) and all future affiliated practices (collectively the "RightMove Professional Entities," "we," "our," or "us").

By clicking "I accept", "I agree", or similar when the option is presented to you, or by accessing or receiving virtual physical therapy services from the RightMove Professional Entities, you consent to receive telehealth services.

Your Telehealth Clinician's Credentials

Your clinician's credentials were available to you when you scheduled an appointment. If you have any questions about these credentials, please contact RightMove support.

Important Information Regarding Your Treatment by Telehealth Clinicians, Including Potential Risks and Benefits

The RightMove Professional Entities offer physical therapy services through licensed physical therapists and other licensed professionals via telecommunications technology (also referred to as "telehealth"). The services provided may also include chart review, appointment scheduling, health information sharing, care coordination and follow-up, and non-clinical services, such as patient education.

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 ensure its integrity against intentional or unintentional corruption.

RightMove Health leverages third-party technology partners to deliver our telehealth services. These partners have executed a Business Associate Agreement (BAA) with RightMove Health and may securely store or process protected health information as part of our telehealth service delivery. Your information is protected and secured throughout our telehealth service.

There are various benefits associated with telehealth services, including improved access to care by enabling you to remain in your home while the clinician consults with you, more efficient care evaluation and management, and obtaining the expertise of a specialist as appropriate.

Possible risks include delays in evaluation and treatment due to deficiencies or failures of the equipment and technologies, and in rare events, our clinician may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled telehealth consult or a meeting with a local care team.

At times, your clinician may seek supervision or consultation with other RightMove Professional Entity or non-RightMove Professional Entity clinicians regarding your treatment or to enhance the services being provided to you. All team members must comply with laws regarding the privacy and confidentiality of your health information.

Exceptions to confidentiality exist in certain situations, including: threat of serious harm to self or others; reasonable suspicion of abuse or neglect of a child, or abuse, neglect, or exploitation of an incapacitated or dependent adult; court order and/or subpoena; permission from you or your parent or guardian (i.e., voluntary release signed by you or your parent or guardian); during supervisory consultations or consultations between treating providers; information shared with an insurance company to collect payments; information released as outlined in the RightMove Professional Entities' Notice of Privacy Practices; and as otherwise permitted or required by law.

Financial Responsibility and Assignment of Benefits

Some or all virtual physical therapy services you receive may be covered by your health plan. However, you understand that your health plan may not pay the full amount of the actual bill for services, and you acknowledge and agree that you are fully responsible for paying the RightMove Professional Entities any amounts not paid by your health plan, including non-covered charges and all copayments, coinsurance, and deductibles.

Payment is expected on or before the payment due date set forth in the statement or bill. You further acknowledge and agree that it is your responsibility to inquire about the costs of RightMove virtual physical therapy services in advance when such costs are unclear to you.

You agree to provide us with proof of insurance and identification upon request, including potentially before an appointment or interaction through which the RightMove Professional Entities provides virtual physical therapy services.

In the event any collection action is necessary to collect amounts you owe to the RightMove Professional Entities, you agree to pay all expenses associated with such action, including but not limited to, collection agency fees and attorneys' fees.

You hereby assign to the RightMove Professional Entities all of your right, title, and interest in any and all health insurance or other health care benefits payable to you or on your behalf by any health plan, including private insurance, Medicare, Medicaid, and any other health plan for medical or other professional services or supplies furnished by the RightMove Professional Entities.

If you claim benefits under Title XVIII of the Social Security Act (Medicare), you hereby certify that the information you provide in applying for payment of such benefits is correct and you specifically authorize the RightMove Professional Entities to release to the Centers for Medicare and Medicaid Services and its Medicare administrative contractors any information needed for this or any related Medicare claim.

Without limiting the foregoing, you authorize the RightMove Professional Entities, third parties working on their behalf, including RightMove Health LLC and its vendors, and/or other affiliates of the RightMove Professional Entities, to release to your health plan information necessary to process claims for payment for services or supplies provided to you, and you authorize direct payment to the RightMove Professional Entities of all benefits payable to you for such services. In the event a health plan pays you directly, you agree to immediately pay such amounts to the RightMove Professional Entities.

Treatment and Confidentiality of Minors

In accordance with state laws, consent for the treatment of a minor can only be authorized by a current legal guardian for the minor.

By clicking "I accept", "I agree", or similar when the option is presented to you, or by accessing or receiving telehealth services from the RightMove Professional Entities, you acknowledge that you understand and agree to the following:

1. You acknowledge that you have read and understand this Consent to Virtual Physical Therapy Services, have been given an opportunity to ask questions, and have had your questions answered to your satisfaction, and you hereby consent to receive services from the RightMove Professional Entities via telehealth technologies. You understand that the RightMove Professional Entities and its clinicians offer telehealth-based medical services, but that these services do not replace the relationship between you and your primary care doctor. You also understand it is up to your clinicians practicing through the RightMove Professional Entities to determine whether your specific clinical needs are appropriate for a telehealth encounter.

2. If you are consenting on behalf of a minor, you represent that you are the parent or legal guardian of the minor and have legal authority to make healthcare decisions on behalf of the minor.

3. You understand that alternatives to telehealth services, such as in-person services, are available to you. In choosing to participate in telehealth services, you understand that some parts of the services involving tests may be conducted by individuals at your location, or at a testing facility, at the direction of your RightMove Professional Entity clinician (e.g., imaging, labs, and/or bloodwork).

4. You understand that you may expect the anticipated benefits from the use of telehealth in your care, but that no results can be guaranteed or assured.

5. You understand that you will not be prescribed any narcotics, nor is there any guarantee that you will be given a prescription at all.

6. You have been given an opportunity to review clinician credentials.

7. You understand that telehealth may involve electronic communication of your personal medical information to other healthcare professionals who may be in other areas, including out of state.

8. You understand that federal and state law requires healthcare professionals to protect the privacy and the security of health information. You understand that the RightMove Professional Entities will implement reasonable safeguards designed to prevent the unauthorized use or disclosure of your health information.

9. You understand that your healthcare information may be shared with other individuals and third-party partners, vendors, contractors, or affiliates for scheduling, billing, care coordination and follow-up, engagement, and/or general communication purposes. Persons may be present during the consultation other than your RightMove Professional Entity provider for training and education, quality assurance and quality improvement, technology issue troubleshooting, workflow continuous improvement, and/or general administrative support. You further understand that you will be informed of the presence of these individuals in the consultation and thus, will have the right to: (a) omit specific details of your medical history/examination that are personally sensitive to you; (b) ask the additional personnel to leave the telehealth examination; and/or (c) terminate the consultation at any time.

10. You consent to the RightMove Professional Entities' use and disclosure of your health information, including sensitive health information afforded special protection under applicable state laws, for purposes of treatment, payment, or healthcare operations and as otherwise described in the Rightmove Professional Entities' Notice of Privacy Practices. You specifically consent to the disclosure of your health information to RightMove Health LLC and RightMove Health LLC partners, vendors, contractors, and/or affiliates to perform services for or on behalf of the RightMove Professional Entities.

11. You understand that there is a risk of technical failures during the telehealth encounter beyond the RightMove Professional Entities' control. You agree to hold the RightMove Professional Entities harmless for delays in evaluation or for information lost due to such technical failures.

12. You understand that if you participate in a consultation, you have the right to request a copy of your medical records which will be provided to you at a reasonable cost of preparation and shipping and delivery.

13. You understand that you have the right to withhold or withdraw your consent to the use of telehealth services during your care at any time, without affecting your right to future care or treatment. You understand that you may suspend or terminate the use of the telehealth services at any time for any reason or no reason. You understand that if you are experiencing a medical emergency, your RightMove Professional Entity provider is not able to connect you directly to any local emergency services.