Dear Patient and/or designated Representative/Caregiver,
You have been advised that your tablet contains confidential information specific to your medical needs. In the unlikely event you lose or misplace your tablet, please call (347) 699-6477 immediately so that we can remotely remove all data from the device to protect your privacy. Please be aware that you will be responsible for any damaged or lost equipment. Health Recovery Solutions (HRS) may share the information collected from your tablet and devices with Home Physicians Group (HPG)
HPG or HRS will not be held liable for any complications, injury, or death that occurs as the result of negligence of tablet or equipment use. Please be advised that this tablet is not meant to provide direct clinical care or replace the advice of your medical provider. The device is meant to be used for educational purposes only and is not intended to diagnose, treat, mitigate, or cure any diseases. The tablet is meant to help schedule your treatment regimen and provide information remotely to your assigned clinician.
Your signature below acknowledges your understanding and agreement to notify HPG if you lose or misplace your device. You also acknowledge that CCIQ may provide Home Physicians Group with all information collected on your device and accompanying devices for the Remote Patient Monitoring (RPM) program.
Your signature below acknowledges your understanding and agreement to notify HRS if you lose or misplace your tablet. You also acknowledge that HRS may provide HPG with all information collected on your tablet and accompanying devices for the Remote Patient Monitoring (RPM)
Your signature below acknowledges you are the only person who should be using the remote monitoring equipment as instructed. You will not use the device for reasons other than your own personal health monitoring. You understand that you can only participate in this program with one Medical Provider at a time. The devices are meant to collect biometric data and transfer those readings to an online website.
It is NOT AN EMERGENCY RESPONSE UNIT AND IS NOT MONITORED 24/7. Call 911 for immediate medical emergencies. You are aware your readings will be transmitted from the monitor to HRS, in a safe and secure manner.
You can withdraw your consent to participate in this program or revoke service at any time by returning the devices. The patient or caregiver will be responsible for returning the equipment to HPG in working order and failure to return equipment will result in the patient being financially responsible in the amount of up to $800.00, to replace missing equipment. By signing this consent, you authorize HPG to charge your credit card on file for the amount necessary to replace missing equipment.
Chronic Care Management (CCM) services include telephone access 24 hours a day 7 days a week for non-emergent, urgent needs, a comprehensive care plan for all health issues, and the ability to get successive routine appointments with your designated primary care provider. CCM will also help manage your care as you move between and among health care providers and or hospitals.
If eligible for services, HPG/Primary Care of Central Florida is designated by me for purposes of providing CCM/RPM and for submitting claims for payment to Medicare or my private insurer. I understand that CCM/RPM benefits are included between provider visits and facilitate me receiving coordinated healthcare. I understand I can only participate in the program with one Medical Provider at a time, and I can withdraw my consent for these services at any time by notifying HPG.
Your signature below releases HRS and HPG/Primary Care of Central Florida from any personal liability that may result from negligent use or use beyond the devices educational intentions. We appreciate the opportunity to partner with you and your physicians to improve post discharge experience.