TeleiCare RPM Enrollment

TeleiCare RPM Enrollment
Please completed this form to enroll in TeleiCare Remote Patient Monitoring Services. This program uses connected medical devices to monitor your health at home.
- Name
  
  First NameLast Name
- Date of Birth
  
  MonthDayYear
  Date
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Email Address
  example@example.com
- Home Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Emergency Contact
  
  First NameLast Name
- Emergency Contact Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Emergency Contact Email Address
  example@example.com
- Insurance Member ID
- Insurance Group Number
- Upload Insurance Card (Front)
  
  Cancelof
- Upload Insurance Card (Back)
  
  Cancelof
- Which condition (s) apply to you? Select all that apply.
  
  HypertensionDiabetesHeart DiseaseWeight ManagementOther
- Are you currently under the care of a provider for these condition (s)?
  
  YesNo
- Do you agree to use a connected monitoring device as part of this program?
  
  YesNo
- Do you have a smartphone?
  
  YesNo
- Are you comfortable using a mobile app?
  
  YesNoNeed Assistance
- I voluntarily consent to participate in the TeleiCare Remote Patient Monitoring program.
  
  I understand:
  
  I may receive a connected medical device to monitor my health from home
  
  My readings may be transmitted electronically to my healthcare team
  
  This program is not a substitute for emergency care
  
  I should call 911 in an emergency
  
  My insurance may be billed for RPM services if applicable
  
  I may withdraw at any time by notifying the clinic
- Do you consent to participate in the RPM program?*
  
  YesNo
- If enrolled, I agree to:
  - Use the device as instructed
  - Take readings as recommended
  - Notify the clinic if the device is not working
  - Return the device if required
- Do you agree to the device use terms?*
  
  YesNo
- I authorize TeleiCare and affiliated providers to bill my insuracne for RPM services. I understand I may be responsible for copays, coinsurance, or deductibles.
- Do you authorize billing for RPM services?*
  
  YesNo
- I acknowledge that my health information will be shared in accordance with HIPPA for treatment, payment, and health operations.
- Do you acknowledge HIPPA policies?*
  
  YesNo
- Patient Signature*
- Patient Representative
- Date Signed*
  
  MonthDayYear
  Date
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