Consent for Telehealth Treatment 

Confluent Health and its partner therapy practices have developed mōviHealth, a platform for the provision of therapy via telehealth.  Telehealth involves the use of video and audio electronic communications technology and enables you to obtain evaluation, treatment, and education from your therapist from any place, including your home.

Telehealth also has some risks and limitations.  These include, but are not necessarily limited to, technical problems that interrupt or stop your visit before it is complete, inadvertent access by third parties to your visit and/or information despite the use of privacy and security measures, the inability of your therapist to provide hands-on treatment, a potentially decreased ability for your therapist to evaluate your condition, and the possibility of miscommunication with your therapist.

There is a risk of being overheard or viewed by persons near you while using telehealth.  While you may choose for family members, friends, guardians, or other trusted individuals to join a telehealth session, you should only access telehealth services while in a location that is free from distractions and intrusions by unwanted individuals.

Your therapist may determine that your condition is more amenable to, or requires, in-person treatment.  You also have the right to determine, at any time and for any reason, that you no longer wish to receive treatment via telehealth.  In that event, your therapist will work with you to arrange for in-person treatment at a therapy clinic.

The laws that protect the privacy and confidentiality of health care information apply to telehealth.  These laws place limits upon the use and disclosure of your health information and require the use of safeguards to protect the privacy and security of that information. You will be provided with a separate Notice of Privacy Practices that describes these matters in more detail.

Please save and/or print a copy of this consent for your records.  A copy of this telehealth consent will be available in your mōviHealth application, in the footer, or at app.movi.health.  You may also contact us at [email protected] to request a paper and/or e-mailed copy.

By providing your electronic signature, you acknowledge your agreement with the following:

• I authorize the staff of this rehabilitation facility to provide treatment to me via telehealth, either as directed by my referring practitioner or pursuant to a plan of care developed by my therapist. 
• I will be given specific information about the evaluation, treatment, and other services that I receive, including the benefits, risks, potential complications, and alternative choices for care, and will have the opportunity to ask questions about same, at the time of my telehealth visits. 
• I will be asked to identify myself and the address of my present location at the outset of each telehealth visit.   
• I have presented myself to this facility for treatment provided by my attending therapist. 
• I understand and acknowledge that the services I will receive may be provided by practitioners who may not be employees of Confluent Health or its partner therapy practices.  I also understand and acknowledge that residents, fellows, or students in therapy education programs may be involved in my care and that they may not be employees or agents of Confluent Health or its partner therapy practices.  I agree that the signing of this document does not imply that Confluent Health and/or its partner therapy practices assume liability for the activities of any such practitioners or individuals. 
• The Notice of Privacy Practices will be available in my mōviHealth user profile, but I may also request a paper and/or e-mailed copy of the Notice of Privacy Practices at any time. 
• I have read and fully understand the above general consent form and will have the opportunity to ask any questions I may have about telehealth to my treating therapist. 
• If I am under 18 years of age, I have the permission of a parent or guardian to utilize mōviHealth and understand that my parent or guardian will be required to execute this Consent and all other required documents on my behalf as a condition of utilizing mōviHealth.