REMOTE PATIENT MONITORING SERVICESPatient Consent and Authorization

Remote Patient Monitoring (“RPM”) is the use of digital technology to collect your health data outside of a clinical setting (for example, while you are at home or at work) and transmit that data to your healthcare provider for evaluation. The type of health data collected may include vital signs, weight, blood pressure, blood sugar, blood oxygen levels, heart rate, and other data that can help your healthcare provider monitor your health and make treatment recommendations. BlueStar Telehealth will be the technical services company that provides the equipment and the software platform to your healthcare provider. By signing below, you acknowledge and agree to the following: 

Your healthcare provider or staff has explained to you what RPM means, the type of health data that will be collected, and how it will be used in your care;

You are aware that your health data will be collected and transmitted digitally from the RPM equipment to your healthcare provider in a safe and secure manner to maintain the confidentiality of your healthcare information;

You will not transmit the health data of any individual other than your own data;

You will not intentionally tamper with the device used to provide these services;

Your healthcare provider is not responsible for inaccuracies in the health data transmitted, or for failure of the data to be transmitted due to equipment problems, wifi or cellular coverage, or improper use of the equipment;

You are responsible for potential copay and deductible amounts; You consent to the use of RPM services as part of your care and treatment; You may share your data with any family member of your choice; and You have the right to withdraw this consent at any time.

I hereby consent to the use of RPM services. By signing, I acknowledge that I have read and understand all of the above.

_____________________________________ __________________________Patient/Responsible Party Signature Date

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BSUH Rev 1.1 of 27 Aug 2020

Printed Name

BSUH Rev 1.1 of 27 Aug 2020