Request for RPM/CCM Services

Request for RPM/CCM Services
TeleMate Health currently has access to our patient data*

TrueFalse
I have attached documents that have the patient name and DOB*

TrueFalse

File Upload

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Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Patient Phone Number*
Please enter a valid phone number.
Patient to begin Chronic Care Management (CCM)?*

YesNo
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 appliedNo = Provider determines peripherals and parameters.
Vital Sign Goals

PLEASE ADJUST PRESET DATA RANGES IF YOU WANT TO CHANGE THE STANDARDIZED PARAMETERS.
Patient to begin Remote Patient Monitoring with the following peripherals:

Blood Pressure MonitorPulse Oximeter with HR MonitorGlucometerScale
Blood Pressure Diastolic (mmHg)
Blood Pressure - Systolic (mmHg)
Heart Rate
O2 Stats
Blood Glucose
Blood Glucometer Testing Frequency

QDBIDTID ACAC and HS
Weight
Weight gain of 2 lbs or more in 2 consecutive days, or 5 lbs in a week
Would you like to add patient notes or information?*

YesNo
Do you have orders for TeleMate Health on this patient?*

YesNo
Patient Notes
Patient Orders
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Provider Signature:

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Nurse Signature

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Verbal Order Received From Provider
Provider Name*

First NameLast NameCredential
Nurse Name

First NameLast NameCredential
Today's Date:*

MonthDayYear
Provider Phone
Please enter a valid phone number.
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Demographic Page (Required)
H&P
Medication List
Hospital Discharge Summary (as applicable)

Request for RPM/CCM Services

Vital Sign Goals

Please choose only the appropriate signature box.