RPM Registration2

REMOTE PATIENT MONITORING

Remote Patient Monitoring Consent Form

* Indicates required field

Member Information *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Primary Care Physician *

Primary Care Physician Phone # *

Date of Birth (ie. 01/25/1955) *

Phone Number *

Email *

Height (ie. 5-8) *

Referred to RPM By *

Medical Devices to Be Received *

Blood Pressure Monitor Pulse Oximeter Weight Scale Glucose Device (select only if Diabetic)

I understand that:
* I am the only person who should be using the remote monitoring equipment as instructed. I will not use the device for reasons other than my health monitoring. I understand that I can only participate with one Medical Provider at a time.

* I will not tamper with the equipment. I understand that I am responsible for any fees associated with the misuse of the equipment.

* I understand that the devices are only designed for the RPM program.

* The device is meant to collect Blood Pressure, Pulse Oximeter, Glucose, and Weight Readings 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.

* I am aware my BP/Pulse Oximeter/Glucose/Weight daily readings will be transmitted from the monitor to a website located at www.eklotho.com safely and securely. I can withdraw my consent to participate in this program and revoke service at any time by returning the devices. The primary care physician listed above will securely and confidentially store my collected data and record and store my readings in my Electronic Medical Record monthly.

* I will do my best to take my BB/Pulse Oximeter/Glucose/Weight every day. I am aware that a Remote Patient Monitoring Qualified Health Professional will view my readings every 30 days, and that this program is NOT a 24/7 Monitoring Service. I will comply with the RPM services expectations and if I don't, I may be removed from the RPM services and will return the medical devices.

**** I have read and understood the information and give consent to participate in the Remote Patient Monitoring program as stated above. I am aware that this consent is valid as long as I'm in possession of the RPM equipment/device.

Patient Consent Confirmed Below

Type Name To Confirm Consent *

Date (ie. 01/25/2023) *

Upload a Single Picture or PDF That Includes: Valid ID, Medicare Card, & Insurance Card *

Max file size: 20MB

Submit

REMOTE PATIENT MONITORING

Remote Patient Monitoring Consent Form

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