Healthcare Monitoring Agreement

HEALTHCARE MONITORING AGREEMENT

This Healthcare Monitoring Agreement (Agreement) is made between Patient Name: and Provider Name: . Effective Date:

Purpose and Scope

Provider will supply remote health monitoring services and related devices as described in this Agreement. The purpose is to permit continuous or periodic collection of health data to support clinical assessment, early intervention, and care coordination. Monitoring services do not replace in-person medical care and are not a guarantee of emergency response.

Patient Information

Insurance Information

Medical History

Monitoring Services and Equipment

Description of monitoring services:

Device(s) issued (check all that apply) and serial number(s):

Patient responsibilities with issued equipment include: maintain device charge and connectivity, wear or use device as instructed, not tamper or share devices, and promptly report malfunctions. Patient agrees to return Provider-owned equipment upon termination.

Data Collection, Use and Disclosure

Patient hereby consents to the collection, storage, transmission and use of physiological and other health-related data obtained through monitoring devices and patient-reported information. Collected data will be used for clinical assessment, care coordination, quality assurance, billing, and as required by law. Provider will implement administrative, physical and technical safeguards to protect patient data consistent with applicable privacy standards.

By signing this Agreement, Patient authorizes Provider to share monitoring data with authorized healthcare providers, designated family members or caregivers for care coordination, and with billing agents as necessary for payment. Patient may revoke this authorization in writing; revocation will not affect disclosures made prior to receipt of revocation.

Risks, Benefits, and Limitations

Patient acknowledges that monitoring may provide earlier detection of certain events and supports remote clinical oversight, but does not guarantee prevention of harm or immediate emergency response. Devices may fail, produce false positives or false negatives, or be affected by connectivity interruptions. Patient accepts these risks and agrees that monitoring is adjunctive to, and not a substitute for, urgent or emergent medical care.

Fees and Billing

Patient is responsible for payment of any co-payments, deductibles or fees not covered by insurance. Provider will bill insurance where appropriate; Patient shall remain responsible for amounts not paid by insurance. Failure to pay when due may result in suspension of monitoring services following reasonable notice.

Term, Termination and Equipment Return

This Agreement begins on the Effective Date and continues until terminated by either party with thirty (30) days written notice or earlier for material breach. Upon termination Patient must return Provider-owned equipment within fifteen (15) days; Patient remains responsible for damage beyond normal wear and tear and for fees associated with non-return.

Liability, Indemnification and Dispute Resolution

Provider's liability for damages arising from monitoring services shall be limited to direct damages and in no event shall Provider be liable for incidental, consequential or punitive damages. Patient agrees to indemnify and hold Provider harmless from claims arising from Patient's misuse of equipment or failure to follow instructions. Disputes arising under this Agreement shall be resolved in accordance with the laws of the state identified below.

Privacy, HIPAA Acknowledgment

Patient acknowledges receipt of Provider's privacy practices summary and understands that protected health information created or received in connection with remote monitoring will be used and disclosed as described herein for treatment, payment and healthcare operations. Patient has the right to request restrictions and to inspect or obtain copies of health information as permitted by law.

Withdrawal of Consent

Patient may withdraw consent to monitoring at any time by providing written notice. Withdrawal of consent will not affect actions taken by Provider prior to receiving notice. If consent is withdrawn, Provider may discontinue monitoring services following a reasonable transition period.

Miscellaneous

This Agreement constitutes the entire agreement between the parties relating to its subject matter. Any amendment must be in writing and signed by both parties. If any provision of this Agreement is held invalid, the remaining provisions will remain in full force and effect.

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