Telehealth and E-Visits
We are pleased to offer teleheath/e-visit services for our patients, which is a video call with your physical therapist. A telehealth visit will replace an in-person visit during the COVID-19 Pandemic. Your physical therapist will ask you about your current symptoms, any changes to your medical history, and have you demonstrate certain range of motion, strength, or functional movements. Your therapist will then ask about your current home exercise program, discuss progressions or regressions, and guide you through specific exercises unique to you.

Health insurance coverage and the type of teleheath visit will vary from company to company. Please look for your carrier below for specific details, including our rate for self pay. Coverage details are changing daily. This form and link will be changed weekly with insurance updates and appointment availability. We are also offering a self-pay rate.

At this time we are unable to provide telehealth services for patients who reside in Maryland due to licensure restrictions. We are able to provide telehealth services only to patients who reside in Virginia and the District of Columbia.

Please fill out the required information below then select a date and time for your virtual visit with your physical therapist.
Email address *
Self-Pay
Current patients, whose insurance does not cover telehealth may elect to have a 30 minute session for $45.
Aetna
Telehealth visits for current and new patients. For current patients, your agreed upon rate towards your deductible, copay, and/or co-insurance applies. For new patients, we will discuss your benefits prior to your first visit.
Carefirst/BCBS/FEP Blue:
Carefirst is waiving member cost for telehealth services. You do not owe copay, co-insurance, or deductible for your telehealth visit. This applies for current and new patients.
Cigna
Telehealth visits for current patients for treatment and new patients for evaluation and treatment. Normal deductible, co-pay, and/or coinsurance applies.
Medicare
Only current patients can receive an e-visit, which allows you to talk to your physical therapist about your current plan of care. Part B deductible and co-insurance applies. Secondary insurances may or may not cover the 20% co-insurance amount.
UnitedHealthcare
UnitedHealthcare is waiving member cost for telehealth services. You do not owe copay, co-insurance, or deductible for your telehealth visit. This applies for current and new patients.
Patient Name (Last, First) *
Telehealth Platform Information
Doxy.me supplies HIPPA compliant video conferencing. You will receive a confirmation email for your selected appointment time with a link to Doxy.me. AT YOUR APPOINTMENT TIME, YOU MUST OPEN THE LINK TO START THE SESSION WITH YOUR PHYSICAL THERAPIST.
Consent *
I understand that telemedicine is the use of electronic information and communication technologies by a health care provider to deliver services to an individual when they are located at a different site than the provider; and hereby consent to Optimal Physical Therapy LLC providing healthcare services to me via telemedicine. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine. As always, your insurance carrier will have access to your medical records for quality review/audit. I understand that I will be responsible for any deductibles, co-payments or co-insurances that apply to my telemedicine visit. I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment. I may revoke my consent orally or in writing at any time by contacting Optimal Physical Therapy LLC at 703-558-4960 or info@optoptimal.com. As long as this consent is in force (has not been revoked) Optimal Physical Therapy LLC may provide health care services to me via telemedicine without the need for me to sign another consent form.
Required
Please select the date and time for your virtual visit with your PT. Be sure the time selected has your physical therapist's name after it.
Monday, April 6, 2020
Tuesday, April 7, 2020
Wednesday, April 8, 2020
Thursday, April 9, 2020
Friday, April 10, 2020
Please enter the required payment information below if you have Aetna or Cigna health insurance or are completing a self-pay visit. Your payment will be completed once the claim is processed by your insurance company, which can be several weeks from the date of service. A receipt will be emailed to you.
Name on Card
Card Numbers
Card Type
Clear selection
Date of Expiration
Cancellation and No Show Policy *
If you need to cancel your telehealth/e-visit please notify the therapist directly by replying to the confirmation email at least 12 hours prior to the scheduled time. THERE IS A $15 CHARGE FOR LATE CANCELLATIONS (LESS THAN 12 HOURS BEFORE) AND NO SHOWS.
Required
Submit
Never submit passwords through Google Forms.
This form was created inside of Optimal Physical Therapy LLC. Report Abuse