Patient Consent Form

Below is a copy of the Patient Consent Form in the GatherMed Platform. 

In order to print this form, please change the bolded text to the appropriate parties first.

This patient consent form (”Consent”) is meant to provide consent to GatherMed and Test Account, and its parents, subsidiaries, affiliates and assigns (collectively “Test Account”), to access, store and review my information, including protected health information. By signing this patient consent form, I Nice Guy, hereby consent to my clinical values as measured by the equipment provided to me by GatherMed on behalf of my primary care provider be monitored by the Test Account Care Management Team with clinical oversight from my primary care provider. I understand that the purpose of the monitoring of my clinical data submitted is to support me in maintaining my health and identify instances where health care interventions may be required to prevent a deterioration to my health. These interventions and recommendations for interventions will be communicated to me via the responsible Care Management team. I understand that: 1) My primary care provider and Test Account have partnered with GatherMed to provide the Remote Patient Monitoring (”RPM”) Program to patients to improve care management of chronic conditions. 2) The Provider / Care Management team will clearly explain the details of the Remote Monitoring Program services to be provided to me that are applicable to my health condition(s). The information will include what will be necessary in terms of my participation in order to best meet the objectives of the remote monitoring program. 3) The GatherMed RPM application used by the Provider / Care Management team and the associated medical device(s) are not a replacement for usual healthcare; they are a complement to assist the providers with long term care management. 4) I will be the only one to use the medical device(s) as instructed by the Provider / Care Management team and I will not use the device for reasons other than health monitoring. 5) The medical device(s) are to be used solely in connection with the RPM services and associated RPM program provided by the Provider / Care Management team and not for any other purpose or use. 6) If I should feel physical distress, I may contact my care management team for advice and make them aware of my condition, but I recognize that the RPM program is not a replacement for emergency services. Calling 9-1-1 for immediate medical emergencies is necessary if I am in distress. The medical device does not replace 9-1-1. 7) I have the right to withdraw my consent to participate in the RPM program and stop receiving RPM services at any time. I may be asked to return the medical device(s) if I choose to withdraw my consent. 8) My data may be used in a blinded and de-identified manner for program evaluation and research purposes. 9) My insurance may cover some or all of the cost of participating in this program, and I may be invoiced for services not covered in full by my insurance. 10) I may access the data transmitted from my medical device(s) by registering for an account with the GatherMed application. I may also request reports from the Provider / Care Management team. 11) Risks to participating in this program are minimal but may include a data and information breach of privacy, or a malfunctioning medical device(s) that gives improper readings. All reasonable efforts are taken by GatherMed, the Provider / Care Management team and my primary care provider to minimize these risks. 12) I have responsibilities which include: a. Understanding that the medical device(s) provided to me are the property of Test Account and my primary care provider. I will not tamper with the medical device(s) and I understand that I may be responsible for any costs and expenses related to the misuse of the medical devices. b. Understanding that my data and medical information obtained from my participation in the RPM program may be considered part of my patient record and may be shared with other healthcare professionals to enhance my care. By signing this consent form, I authorize such professional disclosure. My data and information will be securely transmitted and reviewed at the clinician’s discretion. c. Complying with the RPM program clinical expectation with the understanding that if I do not, I may be removed from the RPM program and may be required to return the medical device(s). d. Informing the Provider/Care Management team of any changes to my insurance information. 13) I have received, read and understand the HIPAA Omnibus Notice of Privacy Practices which I received from Test Account. If completing this consent in hard copy, please sign and date below. Consent may also be provided verbally during your initial assessment call with the Provider / Care Management team. Please keep a copy of this form for your records.