Informed Consent

The Community Wellness Program includes Remote Patient Monitoring and Telehealth services and is offered to certain eligible patients. As an eligible patient who can participate in this program, please read this information carefully. 

By acknowledging your consent below, you understand and agree to the following: 

1. You understand that Remote Patient Monitoring and Telehealth are modes of monitoring patient healthcare and delivering healthcare services via Bluetooth devices, software, and communication technologies  (e.g., internet or phone), to facilitate evaluation and management, diagnosis, consultation,  treatment, education, care management, and self-management of a patient’s healthcare. 
2. You understand that Community Wellness physicians, advanced practice providers, nurses, and other clinical health professionals (“Providers”) provide Telehealth consultations, which are conducted through videoconferencing technology, and your healthcare  Provider will not be present in the room with you. 
3. You understand that you are required to do your part in the program as follows:
   • Vitals reading and reporting 
   • Monthly Telehealth visit 
4. You understand that there are potential risks to the use of Telehealth technology, including but not limited to, interruptions, delays, unauthorized access, defective Bluetooth devices, and/or other technical difficulties. You understand that either your healthcare Provider or you can discontinue the Telehealth appointment if the technical connections are inadequate for your visit. 
5. You understand that you could seek an in-office physician visit rather than obtain care from  Community Wellness Providers, and you are choosing to participate in a Community Wellness Program. 
6. You understand that under the federal Health Insurance Portability and Accountability Act of  1996, Public Law 104-191 and its implementing regulations (collectively, “HIPAA”) and under State information privacy law, your health information is protected (“Protected Health  Information” or “PHI”). You also understand that your healthcare information may be shared with others subject to HIPAA for scheduling or billing purposes. Your PHI will be used and disclosed only in accordance with such applicable laws and regulations. 
7. Further to #6 above, you understand that Community Wellness partners with health information exchanges (HIEs) and that the purpose of HIEs is to improve the coordination, quality, and efficiency of healthcare by allowing authorized healthcare professionals and organizations involved in your care to securely access and share your health information as permitted by law. You have read and understand the information regarding HIEs published by the Office of National Coordinator for Health Information Technology at https://www.healthit.gov/topic/health-it-and-health-information-exchange-basics/health-information-exchange.  You further consent to the exchange and sharing of your health information to authorized participants in the HIEs.
8. You understand that with your explicit consent, Community Wellness team members may record Telehealth calls for the purpose of quality assurance, training, and to enhance service delivery.
9. In an emergency, you understand that the responsibility of your Telehealth Provider may be to direct you to emergency medical services, such as an emergency room, or to call 911 and you will follow such directions.
10. You understand that you are unauthorized to record (audio, video, still photography, etc.) any of your Telehealth visits with a Community Wellness Provider. 
11. You understand you may receive SMS text messages for appointment reminders, feedback, and general health information from Community Wellness. __________ (Patient initials) I consent to receive text messages from Community Wellness at my cell phone number and any number forwarded to it. This consent will apply to all future communications unless I request a change in writing.

12. By acknowledging below, you certify that you: 

    • have read this form and/or had it explained to you 
    • understand the risks and benefits of RPM and Telehealth services 
    • have been given the opportunity to ask questions and such questions have been answered to your satisfaction.