Patient Agreement and Consent Form

Patient Name*

First NameLast Name

I {patientName52} have read and understand the information and consent to participate in TeleMate Health’s programs that may include Remote Patient Monitoring (RPM), Chronic Care Management (CCM), Principle Care Management (PCM), and virtual or in-home visits when needed by TeleMate Health’s program providers. I consent to these services being billed to my insurance and understand that cost-sharing may apply. I am aware that only one provider can bill for these services per month. I also consent to the sharing and receiving of information amongst all my healthcare providers to provide the best continuum of care. 

I {patientName52} understand that:

· I am the only person who should be using the remote monitoring equipment as instructed. I will not use the device for reasons other than my own personal health monitoring.

· I understand the devices are owned by TeleMate Heath and are designated for the Remote Patient Monitoring (RPM) program. I am aware of my ability to discontinue services at any time. If there is discontinuation of services, all equipment will be returned to TeleMate Health within 30 days.

· I am aware that my vital sign readings will be sent directly to a TeleMate Health nurse in a safe and secure manner. I further give TeleMate Health permission to share my results with my provider(s).

· I will do my best to take my readings daily. I am aware that a TeleMate Health nurse will review my readings and may contact me by phone to review my results and progress. I am aware that my nursing team is available to me or my caregiver 24 hours a day/7 days a week. I understand this service does not replace 911 services.

· I understand that the RPM Provider will be reviewing my readings. When abnormal readings are present, the Provider may make recommendations to my current Primary Care Provider (PCP) or other specialist regarding changes or additions to my healthcare (medications, specialty referrals, etc.). Ultimately any changes in my healthcare will come from the PCP or healthcare specialist of my choosing.

· I verbally consent to all aspects of this program.

How will TeleMate Health bill for services on my behalf?*

I have a Medicare Part B Plan that TeleMate Health will bill directlyI have Medicare Advantage Plan that TeleMate Health will bill directlyI wish to pay privately

Patient or authorized party providing verbal consent*

Does this party have medical POA?*

YesNoNot sure

TeleMate Health witness receiving verbal consent*

First NameLast Name

Signature of TeleMate Health witness who received verbal consent*

Date*

Date

Please verify that you are human*