Consent to Virtual Physical Therapy Services

DO NOT USE THIS SERVICE IF YOU MAY BE EXPERIENCING A MEDICAL EMERGENCY. In an emergency situation, please call 911 or go to the nearest emergency room.

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 CA Physical Therapy Services PC, RightMove Physical Therapy Services PLLC, RightMove NJ Physical Therapy Services LLC, and Rightmove NY Physical Therapy Services PLLC (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 the services via telehealth technologies. 

Your Telehealth Provider’s Credentials

Your provider’s credentials were made available to you when you scheduled an appointment. If you have any questions about these credentials, please direct them to your telehealth provider.

Important Information Regarding Your Treatment by Telehealth Providers, 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, 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 to ensure its integrity against intentional or unintentional corruption. There are various benefits associated with telehealth services, including improved access to care by enabling you to remain in your home while the provider consults with you, more efficient care evaluation and management, and obtaining 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 provider may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled telehealth consult or a meeting with your local primary care doctor.

At times, your provider may seek supervision or consultation with other RightMove Professional Entity or non-RightMove Professional Entity providers regarding your treatment or to enhance the services being provided to you. All team members are required to 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 of the 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 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 (or third parties working on their behalf, including RightMove Health LLC) 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 treatment of a minor can only be authorized by a current legal guardian for the minor.

Audio/Video Recording

Telehealth sessions may be audio and/or video recorded, in whole or in part, for quality assurance and training purposes. If recording occurs, [you will be informed at the time recording is occurring,] and the telehealth platform may display a recording indicator.

Recordings are used for internal quality and training [and are not intended to be used to document your clinical care]. Access to recordings is limited to authorized personnel and service providers who support these functions, and recordings are maintained with reasonable safeguards designed to protect confidentiality and security. You may decline recording or ask that recording stop at any time. If you decline or ask that recording stop, we will continue the session without recording when feasible, or we will discuss other available options.

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 receiving services from the RightMove Professional Entities via telehealth technologies. You understand that the RightMove Professional Entities and its providers 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 providers practicing through the RightMove Professional Entities to determine whether or not 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 provider (e.g., labs 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 select a provider from the RightMove Professional Entity that provides services in your state prior to the consult, including a review of the provider’s credentials.] 

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

8. You understand that federal and state law requires health care providers 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 contractors for scheduling and billing purposes. Persons may be present during the consultation other than your RightMove Professional Entity provider in order to operate the telehealth technologies. You further understand that you will be informed of their presence 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 non-medical 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 health care 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 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. In the event of such failure, should you need immediate assistance you should call 911 or go to the nearest emergency room. 

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

13. In the event of an adverse reaction following treatment by telehealth technologies, you understand and agree that you should promptly follow-up with your primary care provider or seek immediate medical attention in the case of an emergency. 

14. You understand that you have the right to withhold or withdraw your consent to the use of telehealth services in the course of your care at any time, without affecting your right to future care or treatment. You understand that you may suspend or terminate use of the telehealth services at any time for any reason or for 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.  

15. You acknowledge that you have read and you understand the disclosures set forth next to the state in which you are located at the time of the telehealth encounter, as set forth in the “State-Specific Disclosures” section below. 

16. You acknowledge that you have read the “Audio/Video Recording” disclosure above. You consent to the audio and/or video recording of your telehealth session(s), in whole or in part, for quality assurance and training purposes.

State-Specific Disclosures

The following disclosures apply to patients located in the states listed below and participating in a telehealth consultation with the RightMove Professional Entity that provides services in that state: 

Alaska: You understand your primary care provider may obtain a copy of your records of your telehealth encounter.  (Alaska Stat. § 08.63.210(C)(2). 

Arizona: You understand that all medical records resulting from a telemedicine consultation are part of your medical record. (Ariz. Rev. Stat. Ann. § 36-3602(D)). 

California: You understand that you have the right to withhold or withdraw your consent to the use of telehealth in the course of your care at any time, without affecting your right to future care or treatment, or, affecting your ability to access covered services from Medi-Cal in the future.  You understand that you have the right to access Medi-Cal covered services through an in-person, face-to-face visit or through telehealth. You understand that Medi-Cal provides coverage for transportation services to in-person services when other resources have been reasonably exhausted. (Cal. Welf. & Inst. Code Ann. § 14132.725(d)). 

Connecticut: You understand that your primary care provider may obtain a copy of your records of your telehealth encounter, and that you can revoke your consent at any time.  (Conn. Gen. Stat. Ann. § 19a-906).  

D.C.: You have been informed of alternate forms of communication between you and a physician for urgent matters.  (D.C. Mun. Regs. tit. 17, § 4618.10). Relevant communications with the physician, including those done via electronic methods shall be documented and filed in your medical record. (D.C. Mun. Regs. tit. 17, § 4618.9). 

Idaho: You understand that your informed consent for the use of telehealth services shall be obtained by applicable law. Idaho Statutes 54-5708. 

Indiana:  If a prescription is issued to you, and subject to your consent the prescriber shall notify your primary care provider of any prescriptions the prescriber has issued for you if the primary care provider's contact information is provided by you. This requirement does not apply if: (A) The practitioner is using an electronic health record system that your primary care provider is authorized to access. (B) The practitioner has established an ongoing provider-patient relationship with the patient by providing care to the patient at least 2 consecutive times through the use of telehealth services. If the conditions of this clause are met, the practitioner shall maintain a medical record for you and shall notify your primary care provider of any issued prescriptions. Ind. Code Ann. 25-1-9.5-7.

If you are a Medicaid patient, you have the right to choose between an in-person visit or telehealth visit. Indiana Medicaid Manual: Telehealth and Virtual Services. 

Iowa: To file a complaint, fill out the complaint form and email it to the medical board at ibmcomplaints@iowa.gov. Iowa Admin. Code 653-13.11(147,148,272C)(13.11(18)). 

As appropriate your provider will identify the medical home or treating physician(s) for you, when available, where in-person services can be delivered in coordination with the telemedicine services. Your provider shall provide a copy of the medical record to your medical home or treating physician(s). Iowa Admin. Code 653-13.11(147,148,272C)(13.11(11)) 

Kansas: You understand that if you have a primary care provider or other treating physician, the person providing telemedicine services must send within three business days a report to such primary care or other treating physician of the treatment and services rendered to you during the telemedicine encounter. (Kan. Stat. Ann. § 40-2,212(2)(d)(2)(A).  

Kentucky: You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here: https://kbml.ky.gov/board/Pages/default.aspx.  

If requested by you, your physician must share the medical record with your primary care physician and other relevant members of your existing care team. Kentucky Board Opinion on the Use of Telemedicine Technologies (2014), as amended September 15, 2022. 

Louisiana: You understand the role of other health care providers that may be present during the consultation other than the telehealth provider.  (46 La. Admin. Code Pt XLV, § 7511). 

Nebraska: If you are a Medicaid recipient, you retain the option to refuse the telehealth consultation at any time without affecting your right to future care or treatment and without risking the loss or withdrawal of any program benefits to which the patient would otherwise be entitled. All existing confidentiality protections shall apply to the telehealth consultation. You shall have access to all medical information resulting from the telehealth consultation as provided by law for access to your medical records. Dissemination of any patient identifiable images or information from the telehealth consultation to researchers or other entities shall not occur without your written consent. You understand that you have the right to request an in-person consult immediately after the telehealth consult and you will be informed if such consult is not available. (Neb. Rev. Stat. Ann. § 71-8505; 471 Neb. Admin. Code § 1-006.05).   

New Hampshire: You understand that the telehealth provider may forward your medical records to your primary care or treating provider.  (N.H. Rev. Stat. § 329:1-d). 

New Jersey: You understand that the telemedicine encounter may be with a provider who is not a physician, and you may specifically request a telemedicine encounter with a physician, which may require a referral to a third-party medical practice. You understand that you have the right to request a copy of your medical information and you understand your medical information may be forwarded directly to your primary care provider or health care provider of record, or upon your request, to other health care providers, including your primary care licensed physical therapist. If you do not have a primary care provider or other health care provider of record, the health care provider engaging in telemedicine or telehealth may advise you  to contact a primary care provider, and, upon request by you, may assist you with locating a primary care provider or other in-person medical assistance that, to the extent possible, located within reasonable proximity to you. N.J. Rev. Stat. Ann. § 45:1-62. 

Ohio: You understand that the telehealth provider may forward your medical records to your primary care or treating provider. Ohio Admin. Code 4731-37-01(C)(4). 

Oregon: If you have a concern or complaint about the providers  providing care to you, you may contact a board agency to assist you. You understand that the provider may ask if you need more detail. ORS 17-52-677.07. See also Or. Medical Board, Statement of Philosophy: Telemedicine (Oct 2, 2020) 

Complaints may be filed with:
Oregon Medical Board
1500 SW 1st Ave., Suite 620
Portland, OR 97201-5847

Complaint Resource Staff:  971-673-2702  |  complaintresource@omb.oregon.gov 

Rhode Island: If you use e-mail or text-based technology to communicate with your provider, then you understand the types of transmissions that will be permitted and the circumstances when alternate forms of communication or office visits should be utilized.  You have also discussed security measures, such as encryption of data, password protected screen savers and data files, or utilization of other reliable authentication techniques, as well as potential risks to privacy.  You acknowledge that your failure to comply with this agreement may result in the telehealth provider terminating the relationship.  (Rhode Island Medical Board Guidelines). 

South Carolina: You understand your medical records may be distributed in accordance with applicable law and regulation to other treating health care practitioners. You understand the value having of having a primary care medical home and, if requested, we can provide assistance in identifying available options for a primary care medical home. S.C. Code Ann. § 40-47-37. 

You also understand that if you are a Medicaid beneficiary, you can withdraw your consent at any time. South Carolina Health and Human Svcs. Dept. Physicians Provider Manual, p. 35 (Feb. 2024) 

South Dakota: You have received disclosures regarding the delivery models and treatment methods or limitations. You have discussed with the telehealth provider the diagnosis and its evidentiary basis, and the risks and benefits of various treatment options. (S.D. Codified Laws § 34-52-3). 

Tennessee: You understand that you may request an in-person assessment before receiving a telehealth assessment if you are a Medicaid recipient. (TN Dept. of Mental Health and Substance Abuse Services. Office of Crisis Services Telecommunications Guidelines, p. 8, (2012) (Accessed Jan. 2024)). 

Texas: You understand that your medical records may be sent to your primary care physician within 72 hours. Tex. Occ. Code Ann. § 111.005. You have been informed of the following notice:

NOTICE CONCERNING COMPLAINTS – Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, acupuncturists, and surgical assistants may be reported for investigation at the following address: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Assistance in filing a complaint is available by calling the following telephone number: 1-800-201-9353, For more information, please visit our website at www.tmb.state.tx.us.   

AVISO SOBRE LAS QUEJAS – Las quejas sobre médicos, asi como sobre otros profesionales acreditados e inscritos del Consejo Médico de Tejas, incluyendo asistentes de médicos, practicantes de acupuntura y asistentes de cirugia, se pueden presentar en la siguiente dirección para ser investigadas: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Si necesita ayuda para presentar una queja, llame al: 1-800-201-9353, Para obtener más información, visite nuestro sitio web en www.tmb.state.tx.us    

Utah: You are able to a (i) access, supplement, and amend your patient-provided personal health information; (ii) contact your provider for subsequent care; (iii) obtain upon request an electronic or hard copy of your medical record documenting the telemedicine services, including the informed consent provided; and (iv) request a transfer to another provider of your medical record documenting the telemedicine services. Utah Admin. Code r. 156-1-602. 

Virginia: You acknowledge that you have received details on security measures taken with the use of telemedicine services, such as encrypting date of service, password protected screen savers, encrypting data files, or utilizing other reliable authentication techniques, as well as potential risks to privacy notwithstanding such measures; You agree to hold harmless [PC] for information lost due to technical failures; and you provide your express consent to forward patient-identifiable information to a third party.  (Virginia Board of Medicine Guidance Document 85-12). 

Vermont: You understand that you have the right to receive a consult with a distant-site provider and will receive one upon request immediately or within a reasonable time after the results of the initial consult. You understand that receiving telehealth services via store-and-forward technologies by [PC] does not preclude you from receiving real-time telemedicine or face-to-face services with the distant provider at a future date. (Vt. Stat. Ann. § 9361).

You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here: http://www.healthvermont.gov/health-professionals-systems/board-medical-practice/file-complaint; Board of Osteopathic Examiners can be found at: https://sos.vermont.gov/opr/complaints-conduct-discipline/#emr (Vt. Board of Medical Practice, Policy on the Appropriate Use of Telemedicine Technologies in the Practice of Medicine (March 1, 2023).

You have read this document carefully, and understand the risks and benefits of the telehealth services and have had your questions regarding the services explained and you hereby give your informed consent to participate in a telehealth consultation under the terms described herein.