Established Provider Referral for RPM/CCM
ONLY USE IF: TeleMate Health has established access to your EMR
Patient Name
*
First Name
Last Name
Patient Date of Birth
*
-
Month
-
Day
Year
Date
Patient Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Provider Name
*
Provider's Practice Name
Patient to begin Chronic Care Management (CCM??
*
Yes
No
TeleMate Health to evaluate and treat for Remote Patient Monitoring (RPM) with standard parameters.
*
Yes = TeleMate Health determines peripherals based on diagnosis and standard parameters are applied
No = Provider determines peripherals and parameters.
Patient to begin RPM and/or CCM with the following peripherals:
Blood Pressure Monitor
Pulse Oximeter with HR Monitor
Glucometer
Scale
Vital Sign Goals
Please slide to indicate changes to parameters. Standard parameters are preset.
Blood Pressure - Systolic (mmHg)
Blood Pressure Diastolic (mmHg)
Heart Rate
O2 Stats
Blood Glucose
Blood Glucometer Testing Frequency
QD
BID
TID AC
AC & HS
Weight
Weight gain of 2 lbs or more in 2 consecutive days, or 5 lbs in a week
Notes:
Provider Signature
Provider - Nurse Verbal Order Signature
Provider Name
*
First Name
Last Name
Credential
Nurse Name
First Name
Last Name
Credential
Today's Date:
*
-
Month
-
Day
Year
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Math Challenge
*
SUBMIT FORM
SUBMIT FORM
TeleMate Health
Should be Empty: