Healthcare HeaRT Agreement

Healthcare HeaRT Agreement

This Healthcare HeaRT Agreement documents the informed consent and authorization for participation in the HeaRT remote monitoring and telehealth program operated by Provider Name: with Patient Name: Program Start Date:

Purpose and Scope

The HeaRT program provides remote physiologic monitoring, clinical review, and telehealth encounters for cardiac care, chronic condition management, and related health services. Patient consents to ongoing collection, transmission, and clinical review of physiologic and device-derived data, electronic communications, and telehealth visits necessary to provide the services described in this Agreement.

Patient Information

Insurance and Billing

Medical History

Program Components & Equipment

The Provider may supply monitoring equipment and a communications device to support remote monitoring. Patient agrees to maintain equipment in good working order and permit remote configuration and software updates as reasonably required for clinical operation.

Equipment provided: Wearable cardiac monitor

Equipment provided: Communications device / tablet

Risks, Benefits, and Alternatives

Benefits may include improved clinical oversight, earlier identification of physiologic changes, and convenient access to clinical staff. Risks include inaccurate or incomplete data transmission, false positives/negatives, technical malfunctions, and potential privacy breaches. Alternatives include in-person care without remote monitoring. Participation is voluntary and may be withdrawn at any time.

Consent to Remote Treatment and Data Transmission

By checking the consent box and signing below, Patient authorizes Provider and its clinical and technical agents to: (1) collect physiologic and device-derived data from supplied equipment; (2) transmit such data electronically to Provider systems; (3) use the data for diagnosis, treatment, care coordination, and program administration; and (4) communicate with Patient by telephone, secure messaging, and telehealth platforms as clinically indicated.

I consent to remote monitoring and telehealth treatment as described above.

HIPAA Authorization and Data Use

Patient authorizes disclosure of protected health information (PHI) collected through the HeaRT program to Provider's treating clinicians, administrative staff, billing agents, contracted vendors performing program functions, and other healthcare providers as necessary for treatment, payment, and healthcare operations. PHI includes physiologic data, device status, clinical notes, and telehealth encounter summaries. Patient understands that records may be retained electronically for program and treatment purposes.

This authorization is voluntary and may be revoked in writing except to the extent Provider has already acted in reliance on it. Revocation does not affect disclosures made pursuant to this authorization prior to receipt of revocation. Authorization expires on:

Fees, Billing and Third-Party Payment

Patient authorizes Provider to submit claims to Patient's insurer and to seek payment for program services and equipment. Patient is financially responsible for co-payments, co-insurance, deductibles, and any equipment replacement fees as permitted by law. Patient authorizes direct billing to the insurance policy identified above.

I authorize billing to my insurer and accept financial responsibility as described above.

Termination; Equipment Return

Provider or Patient may terminate participation at any time. Upon termination Patient shall return equipment according to Provider instructions. If equipment is not returned within the stated return period, Patient may be charged replacement fees consistent with prior notice.

Limitations of Liability; Emergency Care

Patient understands that remote monitoring is not an emergency response service and does not replace emergency medical care. Patient agrees to contact emergency services immediately for urgent or life-threatening conditions. Provider is not liable for delays, interruptions, or loss of data arising from telecommunication failures, equipment malfunction, or Patient noncompliance.

Right to Withdraw and Questions

Patient may withdraw consent at any time by notifying Provider in writing. Withdrawal will not affect disclosures made prior to receipt of the withdrawal. Patient may direct questions regarding program operation, data use, or billing to Provider contact: Phone:

Acknowledgment and Certification

By signing below, Patient certifies that Patient has read and understands this Agreement, has had the opportunity to ask questions and receive answers, and agrees to the terms, including the collection, use, and disclosure of PHI as described herein. Patient affirms that the information provided on this form is true and correct to the best of Patient's knowledge.

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