Dogwood Telehealth Consent Form
The purpose of this document is to obtain your consent of Telehealth occupational therapy services. Due to increasing concerns about the spread of Coronavirus, Dogwood Therapy will only be providing occupational therapy services online until further notice. This means that we will be seeing clients through a variety of internet platforms that are available to the general community. While we will do our best to ensure privacy, we do not have complete control over data collected by the software companies or others who may find their way into the systems platforms. In addition, we may not be responsible for settings on YOUR computer or devices or others within your environment.

The Department of Health and Human Services (HHS) has issued a statement that medical providers and their clients/patients may temporarily use any technology available to provide Telehealth occupational therapy services during COVID-19, regardless of being HIPAA (Health Insurance Portability and Accountability Act) compliant.  We are currently exploring options to guarantee privacy.

“Under this Notice, covered health care providers may use popular applications that allow for video chats, including Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, or Skype, to provide Telehealth without risk that OCR might seek to impose a penalty for noncompliance with the HIPAA Rules related to the good faith provision of Telehealth during the COVID-19 nationwide public health emergency.”

During Telehealth occupational therapy evaluation, treatment and consultation:
We may be discussing details of the clients medical history, evaluations, goals and home plans. It is possible that more than one occupational therapist will be present for the session. A non-medical technician may be present to aid in the scheduling of services, discussion of financial/insurance/copayment or authorization information. Audio, video or photo recordings are used on Telehealth platforms so it is live. We do not store audio, video or photo unless we expressly ask for permission.

Medical Information Confidentiality:
All existing laws about medical information apply to Telehealth occupational therapy sessions. We will make every reasonable effort to avoid confidentiality breaches to sessions. However, we do not have control over all Telehealth platforms or HIPAA at your location, or on your devices.  

Your Rights:
You may refuse or withdraw consent to Telehealth at any time without affecting your right to future care or treatment. You may reapply for OT services at a later date.

It is expected that sessions start within 5 minutes of scheduled time (please do not enter the platform early as we are seeing other clients, and then prepping for yours), and that attendance will be regular with no more than one missed session out of every 5 sessions, and that the missed session will be made up at another time within a 7 day period or a fee of $30 will be charged for each missed session. Please contact us at 505-228-4650 24 hours prior to your session if at all possible. If client is a minor, it is expected that a caregiver will be present to facilitate the session with the supplies we have agreed upon for the agreed duration and frequency of sessions. Clients who participate in ongoing services via Telehealth will have priority when in-person sessions resume so that there is no disruption of services. We are confident that we will be able to resume serving all clients, but the scheduled time may change.

Risks, Consequences & Benefits:
The risks associated with Telehealth is lack of control over platform and environmental privacy issues, injuries may occur without therapist in the room, activities may take longer, transition time may take longer, and similar outcomes. If your family pet will be participating, there is risk of injury to dog and to participant(s)- pets should be in the frame at all times if in the room. There is a chance that some goal areas will be delayed until clinical treatment is restored, if Telehealth appears to not be a good option.
The benefits of Telehealth are supported by research. Research has found that video therapy is as effective as in-person therapy. Most major insurance companies cover Telehealth. If you’re interested in pursuing Telehealth, we will investigate whether you’re eligible for coverage.

I acknowledge that I am responsible for the following to ensure effective and safe Telehealth services:
Access to a smartphone, or iPad of computer with video and audio capabilities. Have internet service or a hot spot. Have completed/updated a Client Packet for Dogwood Therapy Services within the past year. Caregiver available to facilitate sessions with minors as needed, and for discussion of session and potential home plans/strategies.I will be responsible for giving a reasonable effort to implement home-plans/strategies and reporting effectiveness. I understand I have the opportunity to ask questions or express concerns at any time

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