Virtual Care Management Services

Virtual Care Management (“VCM”) is the use of digital technologies to facilitate care management to patients remotely outside of a clinical setting (for example, while you are at home or at work) 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.

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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

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Your Salvo healthcare provider (“Provider”) offers the following VCM services:

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Remote Physiologic Monitoring (“RPM”)

RPM uses digital technologies to gather physiologic data from patients in one location (e.g., their home) and transmit that information to healthcare providers in another location (e.g., their doctor’s office) for analysis. RPM devices/platforms can collect various forms of health data. The type of health data collected may include measurement of inspiratory force using an inhaler and other physiologic data. Your Provider can use this data to monitor your health conditions, provide recommendations, and/or make changes to your care plan.

Chronic Care Management (“CCM”)

CCM aims to improve the coordination and quality of healthcare services for individuals with multiple chronic medical conditions (2 or more) that are expected to last 12 months or more. CCM services typically focus on advanced primary care aspects which include building a continuous relationship between you and your designated care team members, providing support for your chronic conditions, as well as timely sharing of health information, all of which may be performed virtually. CCM patients often require a significant amount of attention, and RPM services often go together with CCM services to help practitioners monitor a patient’s conditions on an ongoing basis without requiring the patient to visit the physician’s office.

By clicking “I Agree” to this patient consent form, you consent to your Provider providing one or both of the above VCM service(s) to you as part of your care and agree to the following:

• Your healthcare provider has explained to you what the applicable VCM service means, the type of health data that will be collected, and how it will be used in your care;
• You are responsible for all applicable copay and deductible amounts (including, if you are a Medicare beneficiary, the 20% copay for Part B services);

• VCM services may only be furnished and billed by one practitioner at a time during a calendar month;
• VCM 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.
• You have the right to withdraw your consent to participate in the VCM program and stop receiving VCM Services at any time by notifying the Provider.

If using a medical device to collect and transmit health data as part of the VCM services, you further acknowledge:

• 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 $125..
• Your 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; and
• Upon withdrawal from the RPM 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.