TERMS FOR AGILIX TELE-MEDICAL NUTRITION THERAPY & REMOTE MONITORING PROGRAM

Medical Nutrition Therapy (MNT) is nutrition-based treatment provided by a registered dietitian nutritionist and includes a nutrition diagnosis as well as therapeutic and counseling services to help manage disease. MNT involves indepth individualized nutrition assessment, establishes goals, a care plan, and interventions, and plans for follow-up over multiple visits to assist with behavioral and lifestyle changes relative to each individual’s nutrition problems and medical condition or disease(s).

 Telemedicine is the exchange of medical information from one site to another through electronic communication to improve a patient’s health. Examples include healthcare services delivered through videoconferencing, online patient portals, and/or audio communications (such as via telephone). Telehealth services substitute for an in-person visit via synchronous, real-time audio and/or video communication.

As a courtesy, Agilix Health will attempt to verify your health insurance benefits and/or may help obtain necessary authorizations for services. However, this is only a quote and provided to us by your health insurance company and not a guarantee of payment. We cannot guarantee payment and cannot verify that definite eligibility of benefits conveyed to us or to you by your carrier will be accurate or complete.

Agilix Health strongly recommends, requests, and encourages you to be familiar with, and verify, your own benefits with your insurance company prior to services being rendered. Please also be aware of any deductible amounts that may interfere with your out-of-pocket expenses for services.

CONSENT FOR MEDICAL NUTRITION THERAPY
I understand that I (or the patient for whom I am legally responsible) am agreeing to services from Agilix Health and Agilix Health’s Registered Dietitians so that I can obtain information and guidance about health factors that are within my (or the patient’s) own control, such as diet, nutrition, and lifestyle.

I understand that the Agilix Health’s healthcare professionals are Registered Dietitians and not medical doctors. Thus, they cannot diagnose medical conditions or treat any disease, but will instead provide nutritional assessment, nutrition care, and counseling to help manage disease and support overall
health and wellness. While nutritional support can be an important complement to my health and disease management, I understand these services are not a
substitute for medical care by a qualified medical provider. Methods of nutrition assessment made available to me are not intended to diagnose disease. Rather, these assessments are intended as a guide to developing an appropriate health-supportive program for me, and to monitor my progress in
achieving my goals. If I suspect that I have a condition that may require medical attention, I will promptly consult with a qualified medical provider. If I am under the care of a medical provider, I agree to contact them and inform them that I am receiving nutritional support and nutritional education and keep my medical provider informed of any changes in my nutritional program. I also agree to inform Agilix Health of any medical care I am currently receiving and medications I am currently taking.

I hereby release and discharge, indemnify, and hold harmless Agilix Health their officers, agents, employees, and persons acting on their behalf, from all claims, demands, costs and expenses, and causes of action, either in law or equity arising out of or in any way connected to services I receive from Agilix Health.

I understand that Sturdy Memorial Hospital will bill my insurance company. I understand that I will be responsible for any co-pays and all deductible and coinsurance amounts that may be billed to me. If my insurance company denies service, I am aware and agree that I am financially responsible for my entire balance due.

I have read this consent form and terms contained herein carefully. I understand the terms of this form fully and voluntarily agree to be bound by them.

Patient or Legal Guardian’s Signature __________________________________________
Relationship to Patient _______________________________________________________
Printed Name _______________________________________________________________
Date _______________________________________________________________________

CONSENT FOR THE USE OF TELEMEDICINE
1. I understand that the purpose of telemedicine is to provide health care services.
2. I permit Agilix Registered Dietitians to use telemedicine in my care.
3. I understand that telemedicine means using phone and/or video to communicate with my health care team instead of seeing my team in person (face-to-face).
4. I understand that reasonable efforts will be made to protect my privacy, though there may be risk of inadvertent disclosure of my personal identifying information and/or protected health information.
5. I understand that I can ask questions and discontinue the use of telemedicine at any time I choose.
6. I understand that telemedicine does not replace other types of medical assessment and care. If I am not improving and have serious health concerns, I will seek immediate medical attention at an emergency facility.
7. ALL OF MY QUESTIONS REGARDING TELEMEDICINE WERE ANSWERED, AND
THE FOLLOWING WAS EXPLAINED TO ME IN A WAY THAT I UNDERSTAND:
• THE CONCEPT OF TELEMEDICINE
• RISKS AND BENEFITS OF THE USE OF TELEMEDICINE

CONSENT FOR THE USE OF REMOTE PATIENT MONITORING (RPM)
Remote Patient Monitoring is the use of digital technologies to collect health data from patients in one location and electronically transmit that information securely to providers in a different location (data can include vital signs, weight,
blood pressure, blood sugar, pacemaker information, etc.).

I understand that:
• I am the only person who should be using the remote monitoring device(s), as instructed. I will not use the device(s) for reasons other than my own personal health monitoring. I understand that I can only participate in this program with one Medical Provider at a time.
• I will not tamper with the RPM device(s). I understand that I am responsible for any fees associated with misuse of the device(s).
• I understand the device(s) are only designed for the RPM program.
• The device(s) is meant to collect vital readings as prescribed by my Medical Provider and transfer those readings to an on-line service. I understand that RPM is NOT AN EMERGENCY RESPONSE UNIT. I understand that I must call 911 for immediate medical emergencies.
• I am aware that my readings will be transmitted from RPM device(s) to a software platform in a safe and secure manner. I can withdraw my consent to participate in this program, and revoke service at any time by returning the device(s).
• I will do my best to take my readings every day. I am aware that a Remote Patient Monitoring Qualified Health Professional will view my readings. I will be contacted, by phone or SMS, to remind me to take my readings, review and discuss my results and progress.

I, _________________________________ have read and understood the information (print your name) and consent to participate in the Remote Patient Monitoring program as stated above. I am aware that this consent is valid as long as I am in possession of the RPM device(s).
Patient or Legal Guardian’s Signature _________________________________________
Relationship to Patient _____________________________ Date ____________________