Remote Patient Monitoring Services

Remote patient monitoring (RPM) is the use of digital technology to collect certain physiological health data about you wherever you are and securely 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 clicking “I Agree” to this patient consent form, you consent to Salvo Health (the “Provider”) providing RPM services (“the RPM Services”) to you on behalf of [PRACTICE] as part of your care and agree to the following:

• Your 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 heart rate data from your use of the medical device will be collected and transmitted digitally from RPM technology, in this case Lohman Technologies’ HomECG+ device, to the Provider in a safe and secure manner to maintain the confidentiality of your healthcare information; 
• You are the only person permitted to use the RPM device and may not transmit or allow to be transmitted the health data of any individual other than your own; 
• The RPM devices provided to you are the property of the Provider. You will not tamper with the RPM devices and are responsible for any costs related to the misuse of the RPM devices. The RPM device is valued at $100.
• Your healthcare provider or their representative may contact you regarding feedback on the RPM Services and these communications may be monitored and / or recorded for quality control;
• You understand this RPM device and RPM Services are not a substitute for keeping your healthcare provider fully informed of your medical condition and any new healthcare developments;
• Your healthcare provider and the manufacturer of this RPM device are not responsible for inaccuracies in the health data transmitted;
• You have the right to withdraw your consent to participate in the RPM program and stop receiving RPM Services at any time by notifying the Provider. Upon withdrawal from the program, you will return the RPM device to the Provider within fourteen (14) days or will be responsible for the full cost of the RPM device;
• 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.

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