REMOTE PATIENT MONITORING(RPM) CONSENT FORM
I am the only person who should be using the remote monitor equipment as instructed. I will not use the device for reasons other than my own personal health monitoring. I understand that I can only participate in his program 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 misuse of the equipment. I am responsible for lost or stolen devices.
I understand that the devices are only designed for the RPM program.
I acknowledge that I received a Quardio BASE 2 weight scale and monitor valued at $500.
The device is meant to collect weight readings and transfer those readings to an online website. My daily weight readings will be transmitted from the scale to a website located at
I can withdraw my consent to participate in this program and revoke service at any time by returning the scale back to HOUSE MD.
I understand that this is not an emergency response unit and is not monitored 24/7. I know to call 911 for immediate medical emergencies.
I am aware that HOUSE MD will securely in confidentially storm I collected data and record in store my readings into my electronic medical record monthly.
I will do my best to take my weights every day, or at least 3 times per week. 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 be contacted every 30 days by phone or secured messaging to review and discuss my results and progress. Certainly I also understand that if there are any abnormalities or treatment must be changed I may be contacted more frequently.
By agreeing to this consent form I have read and understood the information and consent to participate in the HOUSE MD remote patient monitoring program as stated above. I am aware that this consent is valid as long as am in possession of the RPM equipment/weight scale device.
Remote Patient Monitoring Agreement
I have read the above Remote Patient Monitoring Form
I confirm that signing below will be an official signature.