Dear Patient and/or designated Representative/Caregiver,

You have been advised that your devices will transmit data in a secure manner. Please be aware that you will be responsible for any damaged or lost equipment. The third-party provider supplying the devices and services may share information collected from your device with Home Physicians Group (HPG).

Neither HPG nor any third-party provider will not be held liable for any complications, injury, or death that occurs as the result of negligence of equipment use. The device is meant to be used for educational purposes only and is not intended to diagnose, treat, mitigate, or cure any diseases.

Your signature below acknowledges your understanding and agreement to notify HPG if you lose or misplace your device. You also acknowledge that the third-party providers share all information collected from your device and any accompanying devices with HPG as part of the Remote Patient Monitoring (RPM) program.
Your signature below acknowledges that 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 that your readings will be transmitted from the monitor to HPG, 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 $100 per device 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 withdrawal my consent for these services at any time by notifying HPG.

Your signature below releases any third-party provider 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.

Authorization:

I hereby authorize Home Physicians Group to collect and store my credit card information in Prognocis, their electronic health record system. I understand that:

• Only my name, last 4 digits of the credit card number, card issuer (Visa, Mastercard, etc.), and expiration date will be stored.
• Full credit card numbers will not be accessible to any staff.
• The stored information will be used to process payments for co-pays, self-payments, deductibles, and other outstanding balances.
• My credit card will only be charged with my prior verbal consent. Home Physicians Group will always call me to obtain such consent before processing any charges.
• I can revoke this authorization at any time by providing written notice to Home Physicians Group.
• Home Physicians Group will maintain appropriate security measures to protect my credit card information.

Home Physicians Group is committed to protecting your personal information. We have implemented reasonable technical, administrative, and physical security measures to protect your credit card information from unauthorized access, disclosure, alteration, or destruction. However, please be aware that no data transmission over the internet or data storage system can be guaranteed to be 100% secure.

By signing below, I acknowledge that I have read and understood this authorization and agree to its terms.