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Patient Consent Form

Remote Patient Monitoring (RPM) Program

Patient Details

 

Medical Devices Supplied to Patient

The Following Medical Devices have been provided to me (the "Medical Devices" )
By signing the Patient Consent Form, I here by consent to ("the Provider ") providing Remote Patient Monitoring (RPM) services ("the RPM Service ") to me and agree to the following:
  • The Medical Devices provided to me are the property of the Provider. I will not tamper with Medical Devices and I understand that I am responsible for any costs and expenses related to the misuse of the Medical Devices
  • I will be the only one to use the Medical Devices as instructed by the Provider and I will not use device for reasons other than the health Monitoring.
  • The Medical Devices are to be used solely in connection with the RPM Service and associated RPM program provided by the Provider and not for any other purpose or use.
  • The Remote Patient monitoring system Care Remote Patient Monitoring (RPM) system used by the provider, including the Remote Patient monitoring system Patient Application that you will download on your personal smartphone and the associated Medical Devices are not a replacement for usual healthcare; they are a complement to assist us remotely in providing you long term care and health coaching.
  • the RPM program is not a replacement for emergency service. call 9-1-1 for immediate medical emergencies and do not use the medical devices in replacement of the 9-1-1 service.
  • The length of time I am on the RPM program will be determined by the Provider at its sole discreation and I may be removed from the RPM program at any time
  • My data and Medical information obtained from my participation in the RPM program may / may not be considered part of my patient record, but may be share with other health care professionals to enhance my care and I authorize such a professionals disclosure. My data and information will be securely transmitted and reviewed at the clinician's discreation.
  • I will comply with the RPM Program clinical expactations and if I dont, I may be removed from the RPM Program and I will return the Medical Devices.
  • I have the right to withdraw my consent to participate in the RAM program and stop receiving RPM Service at any time.
Provider's Obligations: When Providing the RPM Services, the Provider must
  • Clearly Explain the details of the RPM Services to be provided to you and that are applicable to your conditions.
  • Provide you with an electronic copy of your care plan which is visible in the Remote Patient monitoring system Patient Application
  • Provide you with written confirmation of your revocation from receiving the RPM Services and participatin in the RPM Program, If you revoke your consent.

Patient Consent

in the event that the patient is unable to give consent due to mental or other capacity issues, the relative or carer who has Lasting / Durable Power of Attorney for the health and welfare responsibility, may give consent if deemed to be in the best interest of the patient. In these instances the carer / relative should sign below.