Consent Agreement (Remote Patient Monitoring)

FOR PROVISION OF Remote Patient Monitoring for Eczema By signing this, you consent to your Doctor (referred to as “Provider”) providing remote patient monitoring services (referred to as “RPM Services”) as fully described below. RPM Services are available to you because you have been diagnosed Eczema. RPM Services can help in managing your Eczema under the supervision of a care provider. RPM Services include logging of Eczema severity, triggers and care routine with regular physician review available through the EczemaLess App for patients who meet the following criteria:
  • You must have Eczema
  • You must have an Android or iOS device with internet access which you can operate daily (including use a password)
  • You must have an email address
Provider’s Obligations: When providing RPM Services, the Provider must:
  • If you revoke this Agreement, provide you with a written confirmation of the revocation, stating the effective date of the revocation.
Beneficiary Acknowledgement and Authorization: By agreeing to this Agreement, you agree to the following:
  • You consent to the Provider providing RPM Services to you.
  • You authorize electronic communication of your medical information with other treating providers as part of coordination of your care.
  • You acknowledge that only one practitioner can furnish RPM Services to you during a calendar month. · You understand cost-sharing applies to RPM Services, so you may be billed for a portion of RPM Services even though it does not involve a face-to-face meeting with a Provider.
Beneficiary Rights: You have the following rights with respect to RPM Services:
  • You have the right to stop RPM Services at any time by revoking this Agreement effective at the end of the then-current month. You may revoke this agreement verbally (by calling the provider) or in writing. Upon receipt of your revocation, the Provider will give you written confirmation (including effective date) of revocation.