Consent for Telehealth

The purpose of this form is to obtain your consent to participate in a telehealth consultation for outpatient therapy services with a licensed therapist from Buffalo Rehab Group, Physical Therapy.

The Nature of A Telehealth Therapy Visit:

  • The therapist will use a HIPAA Compliant, interactive video/audio communication platform to treat you.
  • The therapist may perform a “virtual” examination
  • The therapist will not be able to perform hands on treatment such as manual therapy and a telehealth visit may not substitute for all your therapy needs.

Expected Benefits Include:

  • Improved access to therapy services from the patient’s home
  • Obtaining expertise from a specialist
  • More efficient physical therapy intervention
  • Continued progress on your therapy plan of care


  • In rare cases, information transmitted (i.e. a poor video connection) may not be sufficient to allow for appropriate clinical decision making by the therapist.
  • Technical difficulties could result in a missed or incomplete visit which the patient or provider may choose to reschedule.
  • Delays in evaluation or treatment may occur due to equipment deficiencies or failure.

Medical Information and Records:

All existing laws regarding your access to medical information and copies of your medical records apply to these telehealth visits.  Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient information.


Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with a telehealth visit, and all existing confidentiality protections apply to information disclosed during our telehealth visits.


You may withdraw consent to telehealth visits at any time without affecting your right to future care or treatment.

I have read and understand the information provided above regarding therapy telehealth visits.  I understand its contents including the risks and benefits.  I have discussed the applicability of telehealth to my plan of care, and my questions have been answered to my satisfaction.

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Convenient Hours

 Your schedule is important which is why we have appointments available before and after work hours. Although our clinics have different hours many are open from 7am to 7am, some as early as 6am and as late as 8pm. 

Buffalo Rehab Group | Physical Therapy © 2019

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