Please enable JavaScript in your browser to complete this form.

 

Lakeview and Neutrino logo

CONSENT FOR RPM

The following information was explained to the patient during the on-boarding process:

Remote Patient Monitoring (RPM) services involve the collection, analysis and interpretation of digitally collected physiological data, followed by the development of a treatment plan, and management of a patient under the specific treatment plan.

--RPM is use of electronic information and communication technologies by a healthcare provider used to deliver services to an individual when he/she is located at a different location or site

--The exchange of information between the provider and the patient will be done through a secure plaque from/ portal provided by Neutrino RPM and Neutrino RPM will communicate with the patient via phone or in-app secure messaging or email.

-- There are potential risks associated with the electronic exchange of information such as on authorized axis and technical difficulties, which may delay or prevent the transmission of data

--The lost that protect the privacy and the confidential medical information including (HIPAA) also applied to RPM

--There may be copayments or coinsurance responsibilities that applied to RPM services even though it does not involve a face-to-face encounter with the provider

--The patient may unenroll from his/her RPM program at any time by text replying "unenroll" to Neutrino RPM through in-app messaging. Patients can also email to providers.

--Patient was informed that only one provider can furnish RPM services per patient

-- The patient understands the information and has verbally agreed to proceed with receiving RPM services and has no additional questions.

Clear Signature

Consent For RPM