Healthcare Pearl Agreement

HEALTHCARE PEARL AGREEMENT

This Healthcare Pearl Agreement (Agreement) documents the patient’s informed consent to participate in the Pearl program of clinical services, remote monitoring, and data-sharing described below and sets forth the responsibilities and acknowledgements of the patient with respect to clinical care, privacy, fees, and program termination. Patient Name:

Patient Information

DOB:    Gender:

Insurance Information

Relevant Medical History

Program Description, Risks, and Benefits

The Pearl program provides coordinated clinical oversight, remote monitoring of selected physiologic metrics, and secure electronic communications between patient and clinical staff. The program may include device-supplied data collection, patient-reported outcomes, and periodic telehealth consultations. By participating, the patient acknowledges receipt of explanation regarding the nature of services, expected benefits, and potential risks, including but not limited to: incomplete clinical assessment due to remote data limitations, data transmission errors, device malfunction, and limitations on emergency response capabilities.

Patient acknowledges that Pearl services are an adjunct to, not a substitute for, in-person medical evaluation and emergency care. Patient agrees to contact emergency services or present for urgent care when clinically indicated.

Consent and Authorizations

I authorize the Provider and affiliated personnel to enroll me in the Pearl program and to perform the services described above. I authorize the collection, use, and disclosure of my health information as necessary for treatment, care coordination, program operations, billing, and quality improvement.

I understand that I may revoke these consents at any time by providing written notice to the Provider. Revocation will not affect actions already taken based on prior consent.

HIPAA Privacy Authorization

I authorize the disclosure of my protected health information (PHI) as described above for the purpose of treatment, care coordination, program administration, and billing. This authorization permits the Provider to disclose PHI to other treating clinicians, care managers, and program vendors to the extent necessary to provide Pearl services.

This authorization expires on:

If no date is provided, this authorization will expire one year from the date signed unless otherwise required by law. I understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by privacy laws.

Fees, Billing, and Financial Responsibility

The patient is responsible for applicable co-payments, deductibles, or charges not covered by insurance for services rendered as part of the Pearl program. The Provider will bill the patient’s insurance when appropriate; however, the patient remains financially responsible for unpaid balances. Any device loaned to the patient remains the property of the Provider and may be subject to replacement fees if lost or returned damaged.

Term, Termination, and Withdrawal

Participation begins upon signature of this Agreement and continues until: (a) the patient withdraws in writing; (b) the Provider terminates participation for clinical or administrative reasons; or (c) the program is discontinued. Provider will use reasonable efforts to provide notice of termination and transition of care as clinically appropriate.

Data Security, Ownership, and Use

Patient data collected during the program is maintained in clinical records under the Provider’s control. The Provider retains ownership of program systems and analytics, but the patient’s PHI remains subject to legal protections. Aggregated, de-identified data may be used for quality improvement, research, and reporting. The Provider will apply reasonable administrative, technical, and physical safeguards to protect electronic PHI.

Acknowledgements and Certifications

By signing below, I certify that I have read, understand, and received an explanation of this Agreement. I have had the opportunity to ask questions about the Pearl program, risks, benefits, and alternatives, and my questions have been answered to my satisfaction. I acknowledge that participation is voluntary and that I may withdraw at any time.

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