Remote Patient Monitoring Consent Form
As a patient, you may benefit from a new program that our medical facility offers to all our patients. This new program provides remote patient monitoring services offered by our provider, IntelliCare Medical.
I understand that :
- I am the only person who will be using the remote monitoring device(s) as instructed. I will not use the device(s) for reasons 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 confirm that I am not not currently receiving these services from another Medical Provider and agree not to receive these services from a practitioner other than one provided by this medical facility without first revoking this consent form.
- I will not tamper with the RPM device(s). I understand that I am responsible for any fees associated with misuse of the device(s).
- I understand the device(s) are only designed for the RPM program.
- The device(s) is meant to collect vital readings as prescribed by my Provider and transfer those
readings to an on-line service. I understand that RPM is NOT AN EMERGENCY RESPONSE UNIT. I understand that I must call 911 for immediate medical emergencies.
- I am aware that my readings will be transmitted from RPM device(s) to a software platform in a safe and secure manner. My health information will be shared electronically with other health care professionals involved in my care. IntelliCare Medical takes patient privacy very seriously and will continue to comply with all laws related to the privacy and security of your health information.
- I can withdraw my consent to participate in this program, and revoke service at any time by returning the device(s).
- I understand that if I do not return my device(s), I will be charged a fee for replacing the device(s).
- I will do my best to take my readings every day. I am aware that a Remote Patient Monitoring Qualified Health Professional will view my readings. I will be contacted, by phone, or SMS to remind me to take my readings, review and discuss my results and progress.
I, have read and understood the information as stated and I 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 device(s).
By signing this form, I have read and understood the information as stated and I 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 device(s).