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
www.quardiomd.com

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.

First Name *

Last Name *

Email *

Date *

Remote Patient Monitoring Agreement *

I have read the above Remote Patient Monitoring Form

I confirm that signing below will be an official signature. *

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