Blue Moon Senior Counseling

Remote Patient Monitoring Services (RPM) Consent Form

Remote Patient Monitoring (“RPM”) is the use of a digital technology to collect your physiological health data outside of a clinical setting (for example, while you are at home or at work) and transmission of that data to a healthcare provider for evaluation. The type of health data collected may include weight, blood pressure, and other physiologic data that can help your physician or other healthcare provider monitor your health and make treatment recommendations. If you do not understand or agree to any or all of the information below, do not sign this agreement.

Risks and Benefits of RPM

RPM services allow your healthcare provider to monitor your health on an ongoing basis. This may help your healthcare provider identify issues that need to be addressed sooner than they would without RPM and allows you to communicate your information to your provider without having to travel to your provider’s office. RPM relies on devices and a good Bluetooth and/or internet connection to transmit data, and deficiencies in connection may result in missed readings or failure to transmit information.


By signing below, you acknowledge the following:


  • Your physician or other healthcare provider 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 digitally transmitted from an RPM technology 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 any RPM device used in connection with your RPM services;
  • Blue Moon Senior Counseling nor any healthcare provider is responsible for inaccuracies in the health data transmitted;
  • You consent to the use of RPM services as part of your care and treatment;
  • You have the right to withdraw this consent at any time;
  • You are responsible for all applicable copay and deductible amounts (including, if you are a Medicare beneficiary, the 20% copay for Part B services); and
  • RPM services are NOT emergency services and your data WILL NOT BE MONITORED 24/7. If you think you are experiencing a medical emergency, CALL 911 IMMEDIATELY.

By signing below, you acknowledge that you have read and understand all of the above and you consent to receive RPM services from your healthcare provider.

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Signature Certificate
Document name: Remote Patient Monitoring Services (RPM) Consent Form
lock iconUnique Document ID: a76a0b36295487d86ede395864a79b1a4b6e6a94
Timestamp Audit
March 16, 2021 12:23 pm PDTRemote Patient Monitoring Services (RPM) Consent Form Uploaded by Melanie Donohue - IP