Remote Patient Monitoring Services
Patient Consent and Authorization
Remote Patient Monitoring (“RPM”) is the use of a digital technology to collect your physiological health data outside of a clinical setting (for example, while you are at home or at work) and transmit that data to your healthcare provider for evaluation. IF YOU DO NOT UNDERSTAND OR AGREE TO ANY OR ALL OF THE ITEMS BELOW, PLEASE DO NOT PROCEED WITH THESE SERVICES.
By signing below, you acknowledge the following:
- Your physician or other healthcare provider has explained to you what RPM means, the risks, benefits, and alternatives to RPM, the type of health data that will be collected, and how it will be used in your care;
- You are aware that your health data will be collected and transmitted digitally from an RPM technology, such as a blood pressure cuff or other wearable medical device, to your healthcare provider in a safe and secure manner to maintain the confidentiality of your healthcare information;
- You will not transmit or allow to be transmitted the health data of any individual other than your own;
- You will not intentionally tamper with any RPM device used in connection with your RPM services;
- Your physician or healthcare provider is not responsible for inaccuracies in the health data transmitted;
- You consent to the use of RPM services as part of your care and treatment;
- You have the right to withdraw this consent at any time;
- You are responsible for all applicable copay and deductible amounts (including, if you are a Medicare beneficiary, the 20% copay for Part B services); RPM services are NOT emergency services and your data WILL NOT BE MONITORED 24/7. If you think you are experiencing a medical emergency, CALL 911 IMMEDIATELY.
By proceeding with Branch Health by Upside Health, you acknowledge that you have read and understand all of the above, that you have had an opportunity to ask your healthcare provider all of your questions and have had them answered to your complete satisfaction, and you give your informed consent to receive RPM services from your healthcare provider.