Remote Physiologic Monitoring (RPM) Interest Form

Remote Health Monitoring Interest Form

Please fill out the form below if you are interested in signing up for Tarrytown Pharmacy's Remote Health Monitoring Program. We will review your information and contact you soon!
Patient Name*

First NameLast Name
Patient Date of Birth *

MonthDayYear
Date
Please select which next step you would like to take:*

Call Back: A Tarrytown Pharmacy RPM team member will give you a call to answer any questions and discuss next stepsBook an Onboarding Appointment to Receive Free Device (BP Monitor, Scale, or Pulse Oximeter)
Cell Phone Number*
Please enter a valid phone number.
Patient Email*
example@example.com
Patient Address*

Street Address

Street Address Line 2

CityState

Zip Code
Health Conditions
Select the TYPE of health monitoring that you are MOST interested in:*

Blood PressureWeightOxygen LevelsOther
What health conditions are you most interested in monitoring through Blood Pressure?

High Blood PressureCardiovascular DiseaseDiabetesStrokeOther
What health conditions are you interested the most in monitoring through Weight?

Weight LossWeight MaintenancePregnancyHeart FailureOther
What health conditions are you interested the most in monitoring through Oxygen monitoring?

AsthmaChronic Obstructive Pulmonary Disease (COPD)PregnancyHeart FailureOther
Medical Insurance Information
What PRIMARY MEDICAL Insurance do you have?*

Commercial InsuranceMedicare Medical Advantage PlanMedicare Part B ONLY (Medical - Red White and Blue Card)
Select Your Medical Insurance Company*

AetnaBlue Cross Blue ShieldCignaHumanaUnited Health CareOther
Insurance Not Contracted: Unfortunately we are not currently contracted with your Medical Insurance, however we are in the process of working on becoming contracted with your insurance.*

I acknowledge that my insurance is currently not contracted with Tarrytown Pharmacy, but would like to be notified when it is.
Member ID - Medical Insurance Card *
Group ID - Medical Insurance Card*
Card Holder Name*
Please enter the patients' Medicare Number below*
Primary Care Physician
Primary Care Physician Name

First NameLast Name
Primary Care Physician Phone Number
Please enter a valid phone number.
Please let us know any additional information you may want our team to know.
How did you hear about this service?

In-Store at the PharmacyEmailTextOnline SearchOther
Book An Appointment Below for Device Set-up and Training *
Should be Empty:

Remote Health Monitoring Interest Form

Health Conditions

Medical Insurance Information

Primary Care Physician