Telehealth Services Policy Thank You for choosing Accelacare Physical Therapy. We are committed to providing you with the best professional care and are pleased to be able to offer our quality physical services via telehealth. Please carefully read the following, initial where indicated and sign below.FINANCIAL and PRIVACY POLICY: I have read, agreed and signed Accelacare Financial Policy and Notice of Privacy Policy and understand that telehealth services are covered and treated under our policy perimeters for security, payment, insurance billing processing and claim information.Initials* ASSIGNMENT OF BENEFITS: I hereby authorize Accelacare Physical Therapy to bill my insurance company for telehealth services delivered and for my insurance company to remit payments to Accelacare for services rendered.Initials* CONSENT TO EVALUATION AND TREATMENT: I understand that telehealth is the use of electronic information and communication technologies by a health care provider to deliver services to an individual when he/she is located at a different site then the provider. I may withdraw this consent at any time by notifying my provider. I have requested telehealth services at this time and I do hereby consent to treatment by Accelacare Physical Therapy providing services to me via Telehealth.Name* Date* Month Day Year
