Healthcare Digital Health Solutions Form

HEALTHCARE DIGITAL HEALTH SOLUTIONS FORM

Patient Identification

Patient Name:    Date of Birth:

Emergency Contact

Insurance Information

Medical History

Technology Access & Device Data

I have access to the following devices (check all that apply):

Smartphone Tablet Computer Wearable / Remote Monitor

Types of device-generated data authorized for collection and use (check all that apply):

Vitals (e.g., heart rate, BP) Activity / Steps Glucose Sleep

Consent for Digital Health Services

I authorize enrollment in digital health services that may include secure messaging, telehealth consultations, remote monitoring, automated alerts, and integration of device-generated health data into my health record. These services are intended to supplement in-person care and facilitate communication with my care team.

I understand the benefits and risks associated with digital health services. Benefits may include improved access to care, more timely monitoring, and enhanced coordination. Risks include potential technical failures, delays in transmission, inadvertent disclosure of protected health information, and limitations of remote assessment.

I acknowledge that I have the right to withdraw this consent at any time by submitting written notice to the provider. Withdrawal will not affect actions taken in reliance on this consent prior to receipt of revocation.

Consent to participate in Digital Health Solutions:    I consent to participate    I do not consent

Data Sharing, Privacy and HIPAA Authorization

I authorize the use and disclosure of my protected health information created or stored by the digital health solution for treatment, care coordination, and payment as necessary. I understand that disclosed information may include clinical notes, device-generated data, messages, and attachments. The recipient may re-disclose my information and protections may no longer apply.

Authorization to disclose protected health information:    I authorize disclosure as described above

This authorization is effective from the date signed below and expires on:

Electronic Communications Consent

I consent to receive communications related to my care through electronic means, including secure application messages, email, and SMS text messages. I understand standard text messaging rates may apply from my carrier. I acknowledge that electronic communications may not be encrypted and may be intercepted.

Preferred electronic contact method:    Secure app    Email    SMS text    Phone call

Limitations, Risks and Patient Responsibilities

I understand that remote and digital health solutions are not a substitute for emergency care. I will call emergency services for urgent or life-threatening conditions. I accept responsibility for keeping my contact information, device access, and app credentials current.

I understand that data transmission may be delayed or unsuccessful due to technical problems. I agree to follow instructions provided for device use, to report problems, and to notify my care team of significant changes in my health.

Acknowledgements

By signing below I acknowledge that I have read and understand the statements above, that I have had an opportunity to ask questions and that my questions were answered to my satisfaction. I further acknowledge receipt of the practice's privacy notice and understand my rights regarding access to my health information.

I certify that the information I have provided on this form is true and accurate to the best of my knowledge and that I authorize the disclosures and uses described herein.

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