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RPM/CCM Program Consent Form
Remote Patient Monitoring (“RPM”) is the use of a digital technology to collect your physiological health data outside of a facility setting (for example, while you are at home or at work) and transmission of that data to your healthcare provider for evaluation. The type of health data collected may include blood pressure, weight, glucose level, and other physiologic data that can help your physician or other healthcare provider monitor your health and make treatment recommendations. If you do not understand or agree to any or all of the information below, do not provide your consent to participate in RPM.
Risks and Benefits of RPM
RPM services allow your healthcare provider to monitor your health on an ongoing basis in between visits. This may help your healthcare provider identify issues that need to be addressed sooner than they would without RPM and allows you to communicate your information to your provider without having to travel to your provider’s office. RPM relies on devices and a reliable Cellular and Bluetooth connection to transmit data, and deficiencies in connection may result in missed readings or failure to transmit information.
By providing your consent, you acknowledge the following:
- Your physician or other healthcare provider has explained to you what RPM means, 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 digitally transmitted from an RPM technology 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); and
- 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.
- Tenovi is in no way acting as a medical provider. The ultimate responsibility for diagnosing and treating you rests with your healthcare provider.
- You agree to hold all members of ViTel Health and it’s partner Tenovi harmless from and against any damages, liabilities, penalties, losses, costs, and expenses relating to any claim or action relating to ViTel Health and Tenovi’s services or devices.
Physician Attestation
A physician or physician’s staff member verbally provided the above information to each RPM patient prior to initiating RPM services. Verbal consents are not recorded, but the physician or physician’s staff member is required to complete an attestation to evidence the patient’s understanding and consent to participate in RPM services. By providing your verbal consent to a physician or physician’s staff member, you acknowledge that you have read/verbally received and understand all of the above and that you consent to receive RPM services from your healthcare provider. You also understand that a physician or physician’s staff member will provide a digital attestation of your consent for recordkeeping
Physician or Physician's Staff Member Name (Required)
