Remote Patient Monitoring Form Patient DetailsName Language Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code DOB MM slash DD slash YYYY Gender Cell PhonePrimary Insurance ID Number Secondary Insurance ID Number I understand that:- I am the only person who will be using the RPM device(s) provided to me.- I agree to use the equipment as instructed and will not use the device(s) for any reason other than my own personal health monitoring.- I understand that I can only participate in this program with one Medical Provider at a time.- I will not tamper with the equipment and understand that I am responsible for any fees associated with the misuse of this equipment.- I acknowledge that I received _____ RPM device(s), Serial Numbers _____ (provide below).- The device is meant to collect clinical data and send information to my provider's Electronic Medical Record. It is NOT AN EMERGENCY RESPONSE UNIT AND IS NOT MONITORED 24/7. I will call 911 for immediate medical emergencies.- I understand that my data will be electronically transmitted from the monitor to the GeeseMedRPM App on my phone and then to GeeseMed EMR of Healthy Living Primary Care (HLPC) practice in a safe and secure manner. I understand HLPC is a service provider for only the RPM service. I understand my PCP will have access to my vital data and HLPC medical staff/provider furthermore has my permission to discuss my vital data with my PCP on a needed basis. I understand my PCP will remain the same. My data and medical information obtained from my participation in the RPM program may / may not be (select below) considered part of my patient record but may be shared with other healthcare professionals to enhance my care and I authorize such professional disclosure. My data and information will be securely transmitted data and reviewed at the clinician's discretion.- I understand that I can withdraw my consent to participate in this program by returning the device(s) to the office and signing the RPM withdrawal form.- GeeseMed will securely and confidentially store my collected data in my personal Electronic Medical Record.- I will do my best to collect my data every day, or more frequently, as instructed but no less than 16 times per month.- I understand that an RPM Qualified Health Professional will only view my readings periodically and that this program is NOT a 24/7 Monitoring Service. I will be contacted every 30 days, by phone, to review and discuss my results and progress.Number of RPM Device(s) Received Serial Number(s) of RPM Device(s) Received My data and medical information _____ considered part of my patient record.maymay not beDiagnosis Diabetes CHF Hypertension COPD Weight issues Consent I have read and understood the information and consent to participate in the Remote Patient Monitoring program as stated above. I am aware that this consent is valid as long as I'm in possession of the RPM equipment/device.Name of Patient or Auth. Person (Relationship of Auth. Person) Date MM slash DD slash YYYY PCP Phone NumberPOA/Guardian Phone NumberDevice(s) issued by (HLHC staff name and initial) CommentsThis field is for validation purposes and should be left unchanged. Δ RPM_Patient_Consent_form_3.3.23
