Informed Consent for Remote Patient Monitoring Services and Co-Payment

Remote Patient Monitoring (RPM) involves the use of electronic communications and devices that automatically record data to enable healthcare providers at different locations to monitor physiologic metrics and share individual patient medical information for the purpose of managing patient care. RPM services offered by your medical group, CopilotIQ Medical, P.A. (the “Medical Group”) may monitor a variety of physiologic metrics, including, without limitation blood pressure (systolic and diastolic), heart rate, glucose levels (pre and post meal), exercise, weight, steps walked, and sleep quantity and quality. Medical Group has partnered with CopilotIQ, Inc. (“CopilotIQ”) to provide you with the RPM services.

The electronic monitoring systems we use will incorporate network and software security protocols to protect the confidentiality of patient identification and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

These RPM services are an addition to, and not a replacement for, your primary care physician.  Responsibility for your overall medical care should remain with your local primary care doctor, if you have one, and we strongly encourage you to locate one if you do not.

Expected Benefits:

  • Improved access to care by enabling you to remain in your home while a clinical care team obtains results at distant/other sites.
  • More efficient care evaluation and management.

Possible Risks: 

  • Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment and technologies.
  • In rare events, your provider may determine that the transmitted information is of inadequate quality, thus necessitating an in-person meeting with your local primary care doctor.
  • In very rare events, security protocols could fail, causing a breach of privacy of personal medical information.

If you need to receive follow-up care, assistance in the event of an inability to communicate as a result of a technological or equipment failure, please contact your local physician.

By checking the box associated with “INFORMED CONSENT“, you acknowledge that you understand and agree with the following:

  1. I hereby consent to receiving RPM services.  I understand that the RPM services are provided in connection with my current treatment plan with the Medical Group.
  2. I understand that federal and state law requires health care providers to protect the privacy and the security of health information.  I understand that the Medical Group will take steps to make sure that my health information is not seen by anyone who should not see it, in accordance with Medical Group’s standard practices. I understand that RPM services may involve electronic communication or monitoring of my personal medical information to or by other health practitioners or clinical staff who may be located in other areas, including out of state.
  3. I understand there is a risk of technical failures during the RPM services beyond the control of the Medical Group and CopilotIQ.  I agree to hold harmless Medical Group and CopilotIQ for delays in evaluation or for information lost due to such technical failures.
  4. I understand that I have the right to withhold or withdraw my consent to RPM in the course of my care at any time, without affecting my right to future care or treatment. I understand that I may suspend or terminate use of the RPM services at any time for any reason or for no reason.  I understand that if I am experiencing a medical emergency, that I will be directed to dial 9-1-1 immediately and that Medical Group or Medical Group’s clinical staff are not able to connect me directly to any local emergency services.
  5. I understand that I may expect the anticipated benefits from the use of RPM in my care, but that no results can be guaranteed or assured.
  6. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Persons may be present during the consultation other than the Medical Group in order to operate the RPM technologies. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/examination that are personally sensitive to me; (2) ask non-medical personnel to leave the consultation; and/or (3) terminate the consultation at any time.