RPM Consent - White Wilson

Vitals Program Consent

White-Wilson Medical Center and CareTrack are partnering to offer remote patient monitoring (RPM) services to Medicare and Medicare Advantage members. These personalized monitoring kits are pre-configured for immediate use, allowing you and your healthcare team to effectively monitor and manage your chronic health conditions from the comfort of your home.

Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Patient Email*
example@example.com
Patient Phone*
Please enter a valid phone number.
Cuff Size*
What size t-shirt do you wear?
Patient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Terms of Service
- I acknowledge that I am receiving a CareTrack device for vitals monitoring for the purposes of remote monitoring. I acknowledge that this equipment is designed to be used and monitored by my physicians office.
- I understand that by enrolling in the program, I agree to regularly take my readings and to receive monthly check-in calls from CareTrack Health, Inc. These calls are a requirement of the service provided. Failure to take readings or comply with scheduled check-in calls may result in my disenrollment from the service.
- I understand that this equipment is on loan to me and must be returned to either White-Wilson Medical Center, P.A., or or CareTrack Health, Inc., immediately following the discontinuation of remote monitoring service. I have the right to cancel this service at anytime.
- I am responsible for any loss or damage to the equipment while it is in my possession. It is my responsibility to return this device and all related components to White-Wilson Medical Center, P.A. or CareTrack Health, Inc.
- I understand that White-Wilson Medical Center, P.A. will bill my insurance for the use of this device and related care provided to me. However, if my insurance does not cover this device and/or any element of my care, I agree that I will be completely responsible for all amounts due and payable to White-Wilson Medical Center, P.A. and will pay such amount in a timely manner. Failure to pay may result in balances being reported to a credit reporting agency.
- I am aware that allowing someone else to check their vitals on this device is considered fraud on the grounds that inaccurate information will be sent into my medical records which could effect my current therapy.
- I understand that these devices are meant to collect vital readings. This is not an emergency response unit and is not monitored 24/7. Call 911 for immediate medical emergencies.
- I acknowledge and consent to receive SMS text messages from CareTrack Health, Inc. regarding, but not limited to, device readings, program participation, and patient education.
By signing my name below, I understand and agree to the terms presented in the agreement.
Patient/Responsible Party*
Please print full name here
Date*

MonthDayYear
Today's Date
AssessmentId
Should be Empty:

Vitals Program Consent