Permission Form: Remote Patient Monitoring

Last modified: July 22, 2018

Assignment of Benefits and Consent to Co-Payment

Remote Patient Monitoring (RPM) involves the use of electronic communications and devices that automatically record data to enable healthcare providers at different locations to monitor and manage physiologic metrics for the purpose of managing patient care. RPM services offered by Miinedoctor, P.C. (“Miinedoctor”) may monitor and manage a variety of physiologic metrics including, without limitation: blood pressure, blood glucose, oxygen level and/or weight. 

 

By checking the box associated with "REMOTE PATIENT MONITORING SERVICES ASSIGNMENT AND ACKNOWLEGEMENT OF PAYMENT", you acknowledge that you understand and agree with the following:

 

  1. As part of my current treatment plan with my Miinedoctor physician, my physician will be remotely monitoring certain of my physiologic metrics such as blood pressure, blood oxygen level, weight etc. through the use of certain electronic communications, software and devices. 

  2. I understand that these remote patient monitoring services ("RPM”) are separate services for which Miinedoctor will bill my insurance payers, including Medicare or Medicaid.  

  3. I hereby assign to Miinedoctor all my right, title, and interest in any and all insurance payer or other health care benefits payable to me or on my behalf by any insurance payer, including Medicare, Medicaid, private insurance and any other health plan for RPM rendered by Miinedoctor.  The assignment will remain in effect until revoked by me in writing.  I authorize the release of pertinent information necessary to process my RPM claim.  I also authorize direct payment to Miinedoctor of all insurance benefits payable to me for such medical treatment.  In the event an insurance payer pays me directly, I agree to immediately pay such amounts to Miinedoctor.  

  4. I hereby authorize Miinedoctor to share my personal health information with third parties for payment and reimbursement purposes and understand such will only be done as permitted by applicable law. 

  5. I understand that my payer may not cover all of the billed amount.  I understand I am responsible for paying Miinedoctor for any and all of such amounts not paid by my insurance payer, including non-covered charges and all copayments and deductibles.  

  6. I understand that if my insurance requires a referral, I am responsible for obtaining one prior to my appointment.  In the event any collection action is necessary to collect amounts I owe to Miinedoctor I agree to pay all expenses associated with such action, including but not limited to collection agency fees and attorneys’ fees. 

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Chicago, IL USA