MCPST Agreement for E-Communication

Please contact your insurance company to verify if they will cover telemedicine services.

Please contact your therapist to see if they are participating on the telemedicine platform. 

Please complete and sign the MCPST Agreement for E-Communication form and email it to our Administrative Manager Sarah at in order for us to be able to provide telehealth services. If you have any questions,  you may reach Sarah at (608) 237-8000 x 3.

*This form can be filled out on your computer if you prefer. Be sure to download and save the form to your computer first or you will lose what you typed. Click the down arrow to download the form and open it with your computer’s PDF viewer (such as Adobe Reader) – NOT your internet browser. Fill out the form, save the file and print it to sign and return to us.