Request for RPM/CCM Services
Please attach or fax the following:
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Demographic Page (Required)
H&P
Medication List
Hospital Discharge Summary (as applicable)
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Patient Name
*
First Name
Last Name
Patient Date of Birth
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-
Month
-
Day
Year
Date
Patient Phone Number
Please enter a valid phone number.
Patient to begin Chronic Care Management (CCM)?
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Yes
No
TeleMate Health to evaluate and treat for Remote Patient Monitoring (RPM) with standard parameters.
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Yes = TeleMate Health determines peripherals based on diagnosis and standard parameters are applied
No = Provider determines peripherals and parameters.
Patient to begin Remote Patient Monitoring 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 and HS
Weight
Weight gain of 2 lbs or more in 2 consecutive days, or 5 lbs in a week
Notes:
Please choose only the appropriate signature box. It will automatically close the other one.
Provider Signature:
Nurse Signature
Verbal Order Received From Provider
Provider Name
*
First Name
Last Name
Credential
Nurse Name
First Name
Last Name
Credential
Today's Date:
*
-
Month
-
Day
Year
Provider Phone
Please enter a valid phone number.
Please verify that you are human
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