Informed Consent

(Effective January 22, 2024)

Informed Consent for Telehealth Services & In-person Services

We are pleased you have chosen Origin Physical Therapy (FL), PLLC, Origin Physical Therapy (CA), Inc., Clampett Physical Therapy (NY), PLLC, Sullivan Physical Therapy, LLC, Origin Physical Therapy (NJ), LLC, Fiat Physical Therapy, LLC, To The Core Physical Therapy & Conditioning, LLC, and / or The Origin Way, Inc. (individually or collectively referred to herein as "Origin") for your needs.

Consent for Care & Treatment

Your physical therapist (“Physical Therapist” or “Professional”) will complete an initial evaluation consisting of a physical examination and interview. Based on the results of your examination and interview, your Physical Therapist will design an individual treatment program. Your Physical Therapist will use a variety of treatment techniques for the benefit of your care. By clicking agree, you give your consent to Origin to furnish physical therapy care and treatment considered necessary and proper in evaluating or treating my physical condition (the “Services”).

Telehealth Provider Credentials

Your Physical Therapist’s credentials are available on our website. If you have any questions about these credentials, please direct them to your Physical Therapist.

Important Information regarding Your Treatment by Telehealth Health Providers, including Potential Risks and Benefits

Origin, through its Physical Therapists, offers virtual care for patients as a standalone offering and in combination with in-person care.

Virtual visits are similar, but not identical to, physical appointments as the patient will not be physically present with the Physical Therapist. During a virtual visit, patients can expect to receive education regarding their condition(s) and/or concerns, discuss their overall care plan, and receive instructions for home programs including, but not limited to: exercises, pain management strategies, movement strategies, and partner/self manual techniques. The patient can expect that some of this instruction will be active and dynamic, meaning the Physical Therapist will explain and/or demonstrate an exercise or technique, and the patient will then perform the exercise or technique back to the Physical Therapist to observe and make any necessary adjustments. If the patient or the physical therapist has concerns beyond the parameters of a virtual visit, the Physical Therapist may recommend for the patient to be seen in-person by a Physical Therapist or another provider.

Origin offers treatment by physical therapists via telecommunications technology (also referred to as “telehealth” or “virtual”). The services provided may also include chart review, appointment scheduling, appointment reminders, 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 could occur due to deficiencies or failures of the equipment and technologies, and in rare events, our Physical Therapist 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 and/or local physical therapy provider. No party is permitted to record a virtual visit without first obtaining consent from the other party.

By signing this form, you are representing that you have read this document and understand the information found in it, as well as any applicable state disclosures found here.

By checking the box associated with “Informed Consent”, you acknowledge that you understand and agree with the following:

1. You hereby consent to receiving Origin’s Services via telehealth technologies. You understand that Origin and its providers offer telehealth-based physical services, but that these services do not replace the relationship between you and your primary care doctor. You also understand it is up to the Origin provider to determine whether or not your specific clinical needs are appropriate for a telehealth encounter.
2. You have been given an opportunity to select a Physical Therapist from Origin prior to the consult, including a review of the Physical Therapist’s credentials.
3. You understand that federal and state law requires health care providers to protect the privacy and the security of health information. You understand that telehealth may involve electronic communication of your personal medical information to Professionals at a different location.
4. You understand there is a risk of technical failures during the telehealth encounter beyond the control of Origin.
5. 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. You understand that you may suspend or terminate use of the telehealth services at any time for any reason or for no reason. You may not use the telehealth service to receive emergency care or any type of care that requires in-person treatment. Call 9-1-1 or your doctor if you experience a medical emergency.
6. You understand that alternatives to telehealth consultation, such as in-person services are available to you, and in choosing to participate in a telehealth consultation, 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 the Physical Therapist.
7. 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.
8. You understand that your healthcare information may be shared with other individuals for scheduling and billing purposes. Persons may be present during the consultation other than the Origin 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 request the following: (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.
9. You understand that if you participate in a consultation, that you have the right to request a copy of your medical records which may be provided to you at a reasonable fee.
10. 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 below.

Alaska: You understand that your primary care provider may obtain a copy of your records of your telehealth encounter. (Alaska Stat. § 08.84.120(c)(2)).

Arizona: You understand that all medical records resulting from a telehealth consultation are part of your medical record. (A.R.S. § 36-3602).

Colorado: You are informed that if you want to register a formal complaint about a provider, you should file at https://dpo.colorado.gov/FileComplaint.

Connecticut: You understand that your primary care provider may obtain a copy of your records of your telehealth encounter. (Conn. Gen. Stat. Ann. § 19a-906).

Idaho: You understand that your other providers may obtain a copy of your records of your telehealth encounter. (Idaho Code § 54-5711).

Illinois: You have been informed that if you want to register a formal complaint about a provider, you should visit the Illinois Division of Professional Regulation at https://www.idfpr.com/admin/DPR/DPRcomplaint.asp.

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

Kansas: You understand that if you have a primary care provider or other treating physician, the person providing telehealth 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 telehealth encounter. (Kan. Stat. Ann. § 40-2,212(2)(d)(2)(A)). You understand that the complaint process may be found here: http://www.ksbha.org/complaints.shtml.

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). You have been informed that if you want to register a formal complaint about a provider, you should visit: https://dhhs.ne.gov/Pages/Complaints.aspx.

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 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. (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).

South Carolina: You understand your medical records may be distributed in accordance with applicable law and regulation to other treating health care practitioners. (S.C. Code Ann. § 40-47-37).

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.

Texas: You have received guidance on appropriate follow-up care. You understand that your medical records will be sent to your primary care physician within 72 hours of your appointment, and that you can revoke your consent at any time. (Tex. Occ. Code Ann. § 111.005).

Utah: You understand (i) any additional fees charged for telehealth services, if any, and how payment is to be made for those additional fees, if the fees are charged separately from any fees for face-to-face services provided in combination with the telehealth services; (ii) to whom your health information may be disclosed and for what purpose, and have received information on any consent governing release of your patient-identifiable information to a third-party; (iii) your rights with respect to patient health information; (iv) appropriate uses and limitations of the site, including emergency health situations. You understand that the telehealth services meets industry security and privacy standards, and comply with all laws referenced in Subsection 26-60-102(8)(b)(ii). You were warned of: potential risks to privacy notwithstanding the security measures and that information may be lost due to technical failures, and agree to hold the provider harmless for such loss. You have been provided with the location of telehealth company's website and contact information. You were able to select your provider of choice, to the extent possible. You were able to select your pharmacy of choice. Your 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 telehealth services, including the informed consent provided; and (iv) request a transfer to another provider of your medical record documenting the telehealth services. (Utah Admin. Code r. 156-1-603).

Wyoming: You have been informed of the risks of potential technology failures, including the potential loss of medical records or other information, and you provide your informed consent to these risk. You have been informed that providers may photograph, record, videotape, and store records of the services provided to you electronically, and you provide your informed consent to these actions.

Informed Consent for Assessment and Treatment of Pelvic Floor Dysfunctions

We are pleased you have chosen Origin Physical Therapy (FL), PLLC, Origin Physical Therapy (CA), Inc., Clampett Physical Therapy (NY), PLLC, Sullivan Physical Therapy, LLC, and / or The Origin Way, Inc. (individually or collectively referred to herein as "Origin") for your needs.

I understand that if I undertake physical therapy for any pelvic floor dysfunction, it will be beneficial and necessary for my therapist to perform a muscle assessment of the pelvic floor to assess muscle strength, length, range of motion and scar mobility. Palpation of these muscles is most direct and accessible if done via the vagina and/or anal/rectal canal. Pelvic floor dysfunctions include but are not limited to pelvic pain syndromes, urinary incontinence, fecal incontinence, dyspareunia or pain with intercourse, pain from an episiotomy or scarring, vulvodynia, vestibulitis, constipation, pain with urination or defecation, diffuse gluteal pain, organ prolapse, diffuse lower extremity pain, other similar complications. Evaluation of my condition may include observation, direct muscle palpation, soft tissue mobilization, use of vaginal weights, dilators, vaginal or rectal sensors for biofeedback and/or electrical stimulation.

The benefits and risks of the vaginal/rectal assessment have been explained to me. I understand that if I am uncomfortable with the assessment or treatment procedures at any time, I will inform my therapist and the procedure will be discontinued and alternatives will be discussed with me.

Treatment procedures for pelvic floor dysfunctions include, without limitation, education, exercise, neuromuscular reeducation using biofeedback, neuromuscular reeducation, electrical stimulation, ultrasound, use of vaginal weights and several manual techniques including massage, myofascial release, strain counter-strain, ischemic pressure, joint and soft tissue mobilization. Manual therapy techniques may need to be done internally via the vagina and/or anal/rectal canal. The therapist will explain all these treatment procedures to me and I may choose not to participate with all or part of the treatment plan. I understand that unforeseen circumstances may arise which make it necessary or advisable during the course of the procedure to perform different or additional procedures and I consent to the performance of those procedures.

Risks/side effects may include: muscle or joint soreness, slight muscle pain, referred discomfort to another part of the body, fatigue, temporary discomfort with defecation, walking or activities of daily living. Although, extremely unlikely/rare any pelvic exam may increase one's chance of urinary tract infection. I understand that no guarantees have been or can be provided to me regarding the success of therapy.