RPM-CCM Script Order Form

Please complete this form if you are interested in Remote Patient Monitoring. A TeleMate Health representative will call you in the next 2-3 business days.

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Patient Name*

First NameLast Name
Patient Date Of Birth*

MonthDayYear
Date
Patient Phone*
Please enter a valid phone number.
Your Doctor or Provider's Name*
Provider Phone Number
Please enter a valid phone number.
Notes:
I {patientName52} have read and understand the information and consent to participate in the Remote Patient Monitoring and Chronic Care Management program as stated above. I also consent to the sharing and receiving of information amongst all of my healthcare providers in order 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 designated for the RPM program. If there is discontinuation of use, all equipment will need to be returned to TeleMate Health.

·       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 Monday-Friday during normal business hours and may contact me by phone to review my results and progress. This is not a 24 hour monitoring service and 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.
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Date*

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Date
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Please complete this form if you are interested in Remote Patient Monitoring. A TeleMate Health representative will call you in the next 2-3 business days.