TeleiCare Patient Enrollment (RPM & CCM)

TeleiCare Patient Enrollment (RPM & CCM)
Please complete this form to enroll in TeleiCare Remote Patient Monitoring (RPM), Chronic Care Management (CCM), or both programs. This form helps us review eligibility, insurance information, and required consent.
Which program are you enrolling in?

Remote Patient Monitoring (RPM)Chronic Care ManagementBoth
- First Name
- Last Name
- Date of Birth
  
  MonthDayYear
  Date
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Email Address
- Home Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Emergency Contact Full Name
  
  First NameLast Name
- Emergency Contact Phone Number
- Insurance Provider Name
- Insurance Member ID
- Insurance Group Number
- Primary Care Provider Name
- Upload Photo of Insurance Card (Front)
  
  Cancelof
- Upload Photo of Insurance Card (Back)
  
  Cancelof
- Do you have any of the following conditions? Select all that apply:
  
  HypertensionDiabetesHeart DiseaseCOPDChronic Kidney DiseaseObesityDepressionOther
- Do you have two or more chronic conditions expected to last at least 12 months?
  
  YesNo
- Are you currently under the care of a provider for these conditions?
  
  YesNo
- Please list any current medications related to your condition (s)
- Upload Photo of Medication List (if preferred)
  
  Cancelof
- Do you currently use a smartphone?
  
  YesNo
- Are you comfortable using a mobile app?
  
  YesNo
- Preferred Contact Method
  
  Phone CallText MessageMail
- Best Time to Contact You
- If I am enrolled in the TeleiCare Remote Patient Monitoring (RPM) program, I understand that I may be provided with a connected medical device, which may include but is not limited to a blood pressure monitor, weight scale, or pulse oximeter.
  
  I agree to:
  
  • Use the device as instructed by my healthcare provider
  • Take readings as recommended and participate in monitoring as directed
  • Keep the device in good condition and use it only for its intended purpose
  • Notify TeleiCare promptly if the device is lost, damaged, or not functioning properly
  
  I understand that:
  
  • The device may remain the property of TeleiCare
  • The device is provided for medical monitoring purposes only
  • Failure to use the device consistently may affect my participation in the program
  • Failure to return the device, if required upon discontinuation, may result in replacement fees
  
  By agreeing below, I acknowledge that I understand and accept the terms of the device use agreement.
- Do you agree to the device use terms?*
  
  YesNo
- I understand that participation in TeleiCare Remote Patient Monitoring (RPM) and/or Chronic Care Management (CCM) services is voluntary.
  
  I understand that:
  
  • I may withdraw from the program(s) at any time by notifying TeleiCare or my healthcare provider
  • Withdrawal may result in discontinuation of monitoring, care coordination, and related services
  • If I am enrolled in RPM, I may be required to return any monitoring equipment provided
  • Discontinuation of services may impact my ongoing care and provider’s ability to monitor my condition remotely
  
  By agreeing below, I acknowledge that I understand my right to withdraw from the program at any time.
- Do you understand that you may withdraw from the program at any time?*
  
  YesNo
- Patient Signature*
- Patient Representative*
- Date Signed*
  
  MonthDayYear
  Date
Should be Empty: