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
SIGN THIS CONSENT FORM.
By signing below, 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 transmitted digitally from an
RPM technology, such as a blood pressure cuff, 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
- Your physician or healthcare provider is not responsible for inaccuracies in the health
- 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 signing below, you acknowledge that you have read and understand all of the above and you
consent to receive RPM services from your healthcare provider.
Notice of consent is given to the Medical Practitioner and Zemplee.