Before you can connect with a OneStep provider, we ask that you review and sign the below informed consent agreement. In this agreement, you attest that you choose to connect with one of our trusted physical therapists, and that you acknowledge how tele-health services might differ from in-person services. You understand that at any time, you can change your mind about receiving Services and may seek services from a different provider. OneStep provides this form on behalf of our providers. OneStep works with only the best physical therapists, and we trust you will have a great experience.
You agree that it is your choice whether or not to use the Services on the Platform, and that you understand and agree that by using the OneStep service through a Third Party Service Provider (as defined in our Terms of Use), you agree to OneStep sharing your information with the applicable Third Party Service Provider.
This informed consent form hereby includes your consent to request receiving telehealth physical therapy and exercise remediation services from an individual which is part of our network of physical therapists or wellness coaches (each, a “Provider”) remotely through the Celloscope, Inc. (“OneStep”) online digital telehealth platform (the “OneStep Platform”).
Before you give your consent to request such telehealth services from Provider, please be aware of how receiving physical therapy and exercise remediation services from Provider remotely through the OneStep Platform differs from in-person care. The terms “Provider“, “we”, “us”, or “our” refer to the applicable Provider and the terms “you” and “yours” refer to the patient using the OneStep Platform to request telehealth services (the “ Provider Services”) from Provider through use of the OneStep Platform. Please read each item carefully.
You understand that you should never use the OneStep Platform in a medical emergency. You understand that in a medical emergency you should dial 911 or visit an emergency room. You understand that Provider is a physical therapy and exercise remediation telehealth provider and not a full-service medical practice and does not engage in the provision of emergency medical care and treatment.
In using the Provider Services on the OneStep Platform, you understand that you may be provided with the name, credentials, licensure/certification, and qualifications of the Provider who will be providing your care upon request, and that by signing this agreement, you select such Provider prior to receiving the selected Provider Service.
You understand that by using the OneStep Platform for the Provider Services, you will not have an in-person physical exam that might identify a potentially serious medical condition. You also understand and agree that the health information you provide through the OneStep Platform may be the only source of health information used by Provider during the course of your evaluation and treatment through the OneStep Platform, and that Provider may not have access to any other health information held by your previous and/or current medical providers (e.g., allergies, drug reactions, etc.). You understand that you are not guaranteed treatment through the OneStep Platform and that Provider will determine whether or not it is appropriate to treat you through the OneStep Platform. Certain services may require an in-person visit or documentation of an in-person physical examination and you may be referred for in-person care.
You certify that all of the information you provide to the OneStep Platform for the Provider Services is true, accurate, and complete. You understand that if you knowingly provide false, misleading, or incomplete information to a Provider, it may have a negative effect on your treatment and your health. Provider reserves the right to terminate your access to the OneStep Platform if you knowingly provide incorrect information. You understand that you should ask questions about anything you do not understand. You understand that Provider is available to answer any questions you may have when receiving Provider Services through the OneStep Platform.
You understand that by using this OneStep Platform through a Third Party Service Provider, such is paying and will cover your treatment for the time period agreed upon by the Third Party Service Provider and OneStep. You understand you are electing to participate in the OneStep Platform, and that you may be foregoing discounts or insurance coverage that might otherwise be available to you if you sought alternative care options. You understand that in some instances, you may be responsible to arrange and pay for any follow-up care that the Provider recommends you receive.
You understand that by using this OneStep Platform, you are freely electing to pay out of pocket for all Provider Services provided through the OneStep Platform as further detailed in our Terms of Use, and that you may be foregoing discounts or insurance coverage that might otherwise be available to you if you sought alternative care options.
You further understand that the electronic nature of the Provider Services means that there is a greater risk to the privacy of your electronic health information relative to receiving in-person care. By agreeing to use the OneStep Platform, you are consenting to us sharing your personal information, including health information, with certain third parties as more fully described in Provider’s Privacy Policy. Please note that the OneStep Platform is made available through OneStep, a business associate of Provider. For information about OneStep’s privacy and security practices, please read their Privacy Policy on the website. In addition to the information you share with us through the OneStep Platform, the OneStep Platform will also collect your device identifier, Gait Analysis (as more fully described in the OneStep Privacy Policy) and your geolocation. You understand, agree, and expressly consent to us obtaining, using, storing, and disseminating to necessary third parties, information about you and your image, as necessary to provide Provider Services through the OneStep Platform. You further understand that records of Provider Services provided to you through the OneStep Platform may be lost through technical failures and result in a breach of our confidentiality to you. You understand that if you are experiencing technical difficulties through the OneStep Platform, you may email support@onestep.co. You understand that technical issues in the OneStep Platform may result in a delay in receiving Provider Services. In the event of an issue with connecting with the OneStep Platform, the Provider may contact you by phone to continue the Provider Services. You hereby release and hold harmless Provider and OneStep from any loss of data or information due to technical failures associated with the OneStep Platform.
You agree that it is your choice whether or not to use the Provider Services on the OneStep Platform. You understand that at any time, you can change your mind about receiving Provider Services and may seek in-person services from a different provider. If you would like to have the records relating to the Provider Services received through the OneStep Platform sent to your primary care provider, you understand that you will need to request such transfer of such records. You may obtain copies of your medical records for Provider Services by emailing Provider at support@onestep.co. Provider will respond to messages as they are received but does not guarantee an immediate response.
You understand that under applicable state laws, Provider may be required to report suspicions of child abuse, neglect, statutory rape, domestic violence, and sexual assault. OneStep does not become involved in those decisions. You hereby release and hold harmless OneStep and Provider for Provider’s good faith compliance with state mandatory reporting laws.
We make every effort to comply with applicable state laws and regulations with respect to providing telehealth services. You understand that this Informed Consent is intended to incorporate these additional state protections. Should you have any questions about your rights under state law, please contact us.
You hereby consent to the use of telehealth to examine, consult, diagnose, or treat you and you understand that you may seek in-person care or follow up care through other in-person providers should you so choose.
You further acknowledge and agree that:
You are at least eighteen (18) years of age;
You understand that you have read and understood the information above, including the benefits, risks and limitations of using the OneStep Platform for Provider Services, and you may seek in-person care or follow up care with another provider of your choosing;
Provider may share your health records with other health care providers for purposes relating to the provision, coordination or management of your healthcare so that Provider can meet your healthcare needs. This may include information relating to substance abuse, mental health, communicable diseases and other health conditions, subject to the terms in Provider’s Privacy Policy; and
Provider may determine that clinical services are not appropriate for some or all of your treatment needs and may elect not to provide Provider Services to you through the OneStep Platform.
This informed consent will become a part of your medical record.
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