Occupational Therapy Telehealth Informed Consent Form

Patient Information

Name: _________________________ Date of Birth: _________________ Address: _______________________ Phone: _______________________

Consent for Telehealth Services

Nature of Telehealth

I understand that telehealth involves the delivery of occupational therapy services using electronic communications, information technology, or other means between an occupational therapist and a client who are not in the same physical location.

Potential Benefits

• Improved access to occupational therapy care
• Convenience of home-based therapy
• Reduced travel time and costs
• Continuity of care during circumstances preventing in-person visits

Potential Risks

• Technical difficulties or equipment failures
• Limited physical handling and hands-on therapeutic techniques
• Potential privacy/security breaches despite safeguards
• Limited emergency response capability

Patient Responsibilities

I agree to:

1. Provide a safe, quiet, well-lit therapy space
2. Ensure proper internet connectivity
3. Have a responsible adult present if required
4. Not record sessions without prior written consent

Privacy and Security

I understand that:

• All existing confidentiality protections under HIPAA apply
• Electronic systems used will incorporate network and software security protocols
• No guarantee of complete privacy can be made due to the nature of electronic communication

Acknowledgment and Agreement

By signing below, I acknowledge that I have read and understand the information provided above regarding telehealth occupational therapy services.

Patient/Guardian Signature: _________________ Date: _____________

Occupational Therapist: ____________________ Date: _____________

License #: _______________________________