REACTIV, INC. CONSENT FORM AND TELEHEALTH AUTHORIZATION
Last Updated: July 13, 2021
This document will inform you and obtain your consent for care to be provided by an occupational therapist, doing business as Reactiv (“Reactiv”). Please read this document carefully. If you have any questions, please send us a message through our website or email us at firstname.lastname@example.org.
REACTIV DOES NOT PROVIDE MEDICAL CARE ON AN EMERGENCY BASIS ANYWHERE AT ANY TIME AND IS NOT A SUBSTITUTE FOR YOUR PHYSICIAN (PRIMARY CARE OR SPECIALIST). IN THE EVENT OF AN EMERGENCY, CALL 911 OR PROCEED TO THE NEAREST EMERGENCY ROOM. THIS IS NOT AN EMERGENCY SERVICE. PLEASE DO NOT DELAY SEEKING CARE IN A MEDICAL EMERGENCY BECAUSE OF YOUR COMMUNICATION WITH REACTIV.
DESCRIPTION OF CARE
Care may include, but is not limited to, occupational therapy. In general, occupational therapy is intended to treat disease, injury and disability by examination, evaluation, diagnosis, prognosis, and intervention by use of rehabilitative procedures. Reactiv delivers services and information through a telehealth technology platform (the “Platform”) where a licensed therapist will help guide exercises tailored to your specific health care needs.
Benefits of occupational therapy may include:
Aiding individuals to achieve their maximum potential;
Accelerating recovery; and
Reducing the length of time needed for functional recovery.
Risks of occupational therapy may include:
INJURY, INFLAMMATION/SWELLING, BRUISING;
INCREASED PAIN OR DISCOMFORT;
AGGRAVATION OF AN EXISTING INJURY OR CONDITION; and
FATIGUE OR OVER-EXERTION.
RISKS OF USING OUR TELEHEALTH SERVICE
In using our Platform, you accept a greater responsibility to read and understand information throughout the Platform about the limitations of telehealth, the risks of seeking health care information this way, and the risks of a proposed treatment plan. Specifically, you agree to the following risks:
DELAY: There may be a delay until the next business day before a provider reviews any request for treatment and reads any messages sent. You must check the Platform for messages because this is the way that the provider will communicate important information. Failure to check the Platform regularly may delay the services we provide.
NO IN-PERSON EXAM: By using our telehealth platform, you will not have an in-person consultation and physical exam with a practitioner that might identify a medical condition that needs further investigation or immediate treatment.
CONSENT TO COMMUNICATE VIA UNENCRYPTED EMAIL: Our experience is that the overwhelming majority of clients wish to communicate with us via email, even if unencrypted email does not meet HIPAA standards. In signing this consent, you give us permission to use or disclose your medical information to you via the regular email address you provide to us. You acknowledge that we are communicating in this manner irrespective of HIPAA requirements solely at your direction. You may revoke that permission in writing at any time, in which event we will stop any further use or disclosure of your medical information by email, except to the extent we have already acted in reliance on your permission. You understand that we are unable to take back any disclosure we have already made with your permission and that we are required to retain our records of the communications prior to any revocation of authorization to utilize email.
Response to occupational therapy intervention varies from person to person; hence, it is not possible to accurately predict your response to a specific treatment or exercise protocol. As with any other health care treatment, a small percentage of patients do not respond to this therapy. Reactiv does not guarantee what your reaction will be to a specific treatment, nor does it guarantee that the treatment will help resolve the condition that you are seeking treatment for.
NO DUTY OF CARE
Please note that Reactiv does not take responsibility for your health or ongoing care. Instead, we provide a highly focused, next generation perspective and approach, offering exercises to help you recover and regain functionality faster. Visiting Reactiv’s website and making payment, starting a visit, or sending a message to us does not create a duty of care or a provider-patient relationship.
RIGHT TO DECLINE CLIENT
Please understand that Reactiv reserves right to refuse to provide services if, in our professional judgment, you are not a good candidate for our services.
COMMUNICATION AND PATIENT RIGHTS
It is very important to communicate with your treating occupational therapist throughout your treatment. It is your right to discuss the potential risks and benefits involved in your treatment. You are encouraged to ask questions concerning the treatment, discuss the treatment with your provider, and have had all of your questions answered
It is your right to decline any part of your treatment at any time before or during treatment, should you feel any discomfort or pain or have other unresolved concerns. It is your right to ask your occupational therapist about the treatment they have planned based on your individual history, occupational therapy diagnosis, symptoms, and examination results.