Healthcare Technology Interventions Form

HEALTHCARE TECHNOLOGY INTERVENTIONS FORM

Patient Name:   Date of Birth:   Medical Record No.:

Patient Information

Insurance Information

Medical History (Relevant to Technology Use)

Technology Intervention Details

Intervention Coordinator:   Provider / Department:

Telehealth (video/phone)    Remote monitoring device    Mobile application
Wearable sensor    Assistive device    Other:

Start Date:   Anticipated End Date:   Device/Software Serial or ID:

Data Collection, Storage, and Access

The technology will collect, transmit, and store data as necessary to provide clinical care. Types of data that may be collected include (check all that apply):

Biometric readings (e.g., heart rate, blood pressure)    Activity / movement    Audio
Video    Location    Device diagnostic data

Data will be stored in secured systems controlled by the health care provider and may be accessed by members of the care team for treatment, billing, quality assurance, and care coordination. Data may also be shared with authorized third-party vendors involved in device operation and maintenance when necessary for the provision of services.

Risks, Benefits, and Alternatives

Benefits may include improved monitoring, timely clinical intervention, and enhanced patient engagement. Risks may include device malfunction, data transmission failures, privacy breaches, false alarms, or inappropriate reliance on device data. Alternatives to the proposed technology-based intervention include in-person clinic visits and traditional monitoring approaches.

Patient Responsibilities and Device Handling

The patient agrees to follow device use instructions, charge and maintain devices, report malfunctions promptly, and protect device access credentials. The patient is responsible for returning loaned devices in good working condition by the agreed return date or for reimbursing replacement/repair costs if lost or damaged through negligence.

Training, Support, and Troubleshooting

Training will be provided on device operation, data interpretation limitations, and steps to take in case of device alerts or failures. The patient must contact the clinical team for medical concerns; technology alerts do not replace emergency services.

Training completed: Yes   Date of Training:   Trainer Name:

Privacy Notice and Acknowledgment

I acknowledge that the use of this technology involves collection and transmission of my health information. The health care provider will safeguard information in accordance with applicable privacy and security policies. I understand that absolute confidentiality cannot be guaranteed when data is transmitted electronically.

I acknowledge receipt of the privacy notice and my rights regarding access, amendment, and revocation as described below.

Acknowledgment of Privacy Notice: I acknowledge I have received and read the privacy notice and understand how my data will be used.

Authorization and Consent

By signing below I authorize the health care provider to initiate the described technology intervention. I authorize collection, storage, and disclosure of data to the care team and authorized third parties for treatment, payment, and health care operations as necessary. I understand I may revoke this authorization at any time in writing, except to the extent that action has already been taken in reliance on this authorization.

This authorization will remain in effect until: or until revoked in writing.

I consent to the use of the technology and the processing of my data for the purposes described above:    I consent

I understand the alternatives, benefits, and risks, and I have had an opportunity to ask questions which have been answered to my satisfaction.

Patient Rights and Revocation

The patient has the right to inspect and obtain copies of information collected through the technology and may request amendment of inaccurate information. To revoke this authorization, the patient must provide written notice to the health care provider at the address provided in the clinical setting. Revocation will not affect disclosures already made in reliance on this authorization.

Statement of understanding: I understand my rights and the provisions of this form.

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