I authorize the release of the items below (if applicable). I understand these records will only be used to aid in my treatment, and will not be released to any person or agency without my authorization:

• Most recent doctor's note
• EKG, echocardiogram, stress test and catheterization report
• GOLD grouping, 6MWT, spirometry, DLCO, and other relevant pulmonary function testing
• Discharge summary
• Medical history, including medication list

1. Purpose and Explanation of Procedure
The purpose of this consent is to inform you of the following: 1. How Carda Health and the treating Exercise Physiologist will use and disclose the information you share, 2. What other entities Carda Health might share information with, and 3. the risks associated with this telerehabilitation (Telerehab) encounter.

In order to improve my physical capacity and generally aid in my medical treatment for heart disease, I hereby consent to enter a virtual rehabilitation program that will include telemedicine visits, cardiovascular and/or blood oxygenation monitoring, physical exercise, dietary counseling, smoking cessation, stress reduction, and health education activities. The levels of exercise that I will perform will be based on the condition of my heart and circulation as determined by my care team. Professionally trained clinical personnel will provide leadership to direct my activities and may monitor my heart rate and blood pressure to be certain that I am exercising at the prescribed level. I understand that I am expected to attend every session and to follow staff instructions with regard to any medications that may have been prescribed, exercise, diet, stress management, and smoking cessation.

In the course of my participation in exercise, I will be asked to complete the activities unless such symptoms as fatigue, shortness of breath, chest discomfort, or similar occurrences appear. At that point, I have been advised that it is my complete right to stop exercise and that it is my obligation to inform the program personnel of my symptoms. I recognize and hereby state that I have been advised that I should immediately upon experiencing any such symptoms inform the program personnel of my symptoms. I understand that during the performance of in home exercise, a trained observer will periodically monitor my performance and monitor my blood pressure and heart rate, or make other observations for the purpose of monitoring my progress and/or condition. I also understand that the observer may reduce or stop my exercise program when findings indicate that this should be done for my safety and benefit.

2. Risks
It is my understanding that there exists the possibility during exercise of adverse changes including abnormal blood pressure; fainting; disorders of heart rhythm; and very rare instances of heart attack, stroke, or even death. Every effort will be made to minimize these occurrences through risk stratification, proper staff assessment of my condition before each exercise session, staff supervision during exercise, and my own careful control of exercise effort. 

I understand and accept that Telerehab communication has associated risks as compared with in-­‐person healthcare consultation. I understand there are limitations in completing a physical examination for a clinician; it may be more difficult for a clinician to manage some of my complaints or urgent problems, in which case I may be provided with information on how to seek urgent care. I also accept that there is increased risk of miscommunication with my healthcare provider, there is increased risk of interception of this communication, there are more uncertainties related to my privacy. I understand that if I become uncomfortable with any of these limitations of Telerehab, that I have the right to terminate the session at any time.  Further, I understand that Telerehab is not the same as in-­‐person healthcare services and if the exercise therapist feels that I would be a better candidate for in-­‐person sessions that I may be requested by my clinician to attend such sessions at an appropriate location and that that is my choice. I understand that I will be provided with remote monitoring devices as part of the program and that I am the only person who should be using the remote monitoring device(s) as instructed. I will not use the device(s) for reasons other than my own personal health monitoring. I am aware that my readings will be transmitted from RPM device(s) to a software platform in a safe and secure manner. 

3. Benefits to Be Expected
I understand that this medical treatment may or may not benefit my health status or physical fitness. Generally, participation will help determine what recreational and occupational activities I can safely and comfortably perform at home or on my own. Many individuals in such programs also show improvements in their capacity for physical work. For those who are overweight and able to follow the physician's and dietitian's recommended dietary plan, this program may also aid in achieving appropriate weight reduction and control.

 

4. Confidentiality and Use of Information
I understand that Carda Health may collect, use and disclose my personal information and my personal health information for purposes of:

• Assessing, treating or providing other health related services by using virtual internet or telephone communication strategies (TeleRehab).

• Providing treatment outcomes and identifying future rehab services that may be provided.

• Enabling an insurer or funder to determine any potential funding coverage further to my claim.

• Seeking payment for the services I received.

I authorize my TeleRehab Provider and its authorized agents to use or disclose my personal information and my personal health information to any other parties involved in my healthcare as reasonably required. Such parties may include a physician, another healthcare provider, an additional member of Carda Health’s treatment team, relevant funders or payors, referral sources or my employer if it relates to the demands of my job, my functional ability or my ability to return to work.

I have been informed that the information obtained from this rehabilitation program will be treated as privileged and confidential and will consequently not be released or revealed to any person without my express written consent. I do, however, agree to the use of any information for research and statistical purposes as long as it does not identify my person or provide facts that could lead to my identification.

I agree that Carda Health may use my email address and other contact information as a means of providing me information regarding my healthcare, including Telerehab, exercise progressions, appointment bookings and account notifications.

5. Acknowledgement
I acknowledge that I have read this page in its entirety. I further understand that there are remote risks other than those previously described that may be associated with this program. Despite the fact that a complete accounting of all remote risks is not entirely possible, I am satisfied with the review of these risks that was provided to me, and it is still my desire to participate.

 

Please keep in mind that communications via text or email over the internet are not secure. When you agree to get unsecured texts or emails from Carda, you are agreeing to get messages that may reveal your protected health information (PHI). Your health information may be at risk because it could possibly be intercepted and read by other parties besides the person to whom it is addressed or it might be accessed while in your email account. By agreeing to receive text or email communications in this manner, you understand that your PHI is unprotected via this unsecured channel. You can unsubscribe from these emails at any time or text STOP to unsubscribe from text messages.