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Purpose and Explanation of Procedure
The purpose of this consent is to inform you of the following: 1. How Carda Health P.S.C. / Cupid Medical, P.S.C., (“Medical Group”) and the treating Exercise Physiologist will use and disclose the information you share, 2. What other entities Medical Group might share information with, and 3. the risks associated with this telerehabilitation (Telerehab) encounter.
Telerehab involves the use of audio, video or other electronic communications to interact with you, consult with your healthcare provider and/or review your medical information for the purpose of diagnosis, therapy, follow-up and/or education. You agree to the use of the Telerehab platform utilized by Medical Group. You understand: The use of telehealth is voluntary, and I may withdraw my consent to, or stop receiving services through telehealth at any time. There are limitations or risks related to receiving services through telehealth as compared to an in-person visit as described below.
In order to improve my physical capacity and generally aid in my medical treatment for heart disease, I hereby consent to enter a virtual cardiac rehabilitation program that will include telemedicine visits, cardiovascular monitoring, physical exercise, dietary counseling, smoking cessation, stress reduction, and health education activities. The levels of exercise that I will perform will be based on the condition of my heart and circulation as determined by my care team. Professionally trained clinical personnel will provide leadership to direct my activities and may monitor my heart rate and blood pressure to be certain that I am exercising at the prescribed level. I understand that I am expected to attend every session and to follow staff instructions with regard to any medications that may have been prescribed, exercise, diet, stress management, and smoking cessation.
In the course of my participation in exercise, I will be asked to complete the activities unless such symptoms as fatigue, shortness of breath, chest discomfort, or similar occurrences appear. At that point, I have been advised that it is my complete right to stop exercise and that it is my obligation to inform the program personnel of my symptoms. I recognize and hereby state that I have been advised that I should immediately upon experiencing any such symptoms inform the program personnel of my symptoms. I understand that during the performance of in home exercise, a trained observer will periodically monitor my performance and monitor my blood pressure and heart rate, or make other observations for the purpose of monitoring my progress and/or condition. I also understand that the observer may reduce or stop my exercise program when findings indicate that this should be done for my safety and benefit.
Remote Patient Monitoring Program:
Daily Check-Ins:
You may be asked to participate in daily vital check-ins, including monitoring of blood pressure, heart rate, oxygen saturation and other relevant indicators of health. This information will assist in tracking your day-to-day health status and contributing to the personalized rehabilitation plan.
Chronic Care Management (CCM) program:
You may be placed on a medical hold and asked whether you would like to participate in a Chronic Care Management program while we coordinate with your cardiologist / pulmonologist/ physician to gather more information on your condition to ensure you can safely participate in our program. During the CCM program, your dedicated care management team will keep you informed and design a care plan for you.
Chronic Care Management withdrawal:
You have the right to withdraw your participation from Chronic Care Management at any time. If you choose to withdraw, please notify your Exercise Physiologist so that they can take appropriate action. You understand that you can only be enrolled in one such CCM program at a time.
Overnight Pulse Oximeter Readings:
If eligible, you will be provided with a continuous oxygen saturation device that will be used for supervised sessions and overnight pulse oximeter readings. You will be asked to wear the device during sleep to monitor blood oxygen levels throughout the night. This data is essential for assessing respiratory patterns during sleep and ensuring effective rehabilitation and treatment strategies.
By participating in the daily check-ins and overnight pulse oximeter readings, you contribute to the following:
- Personalized Care: Tailoring the rehabilitation plan to your specific needs.
- Progress Monitoring: Assessing improvements and adjusting interventions accordingly.
- Overall Program Effectiveness: Enhancing the quality of care provided during your participation in Medical Group services.Remote
Remote Patient Monitoring Withdrawal:
You have the right to withdraw your participation from remote patient monitoring at any time. If you choose to withdraw, please notify your Exercise Physiologist so that they can take appropriate action.
2. Risks
It is my understanding that there exists the possibility during exercise of adverse changes including abnormal blood pressure; fainting; disorders of heart rhythm; and very rare instances of heart attack, stroke, or even death. Every effort will be made to minimize these occurrences through risk stratification, proper staff assessment of my condition before each exercise session, staff supervision during exercise, and my own careful control of exercise effort.
I understand and accept that Telerehab communication has associated risks as compared with in-‐ person healthcare consultation. I understand there are limitations in completing a physical examination for a clinician; it may be more difficult for a clinician to manage some of my complaints or urgent problems, in which case I may be provided with information on how to seek urgent care. I also accept that there is increased risk of miscommunication with my healthcare provider, there is increased risk of interception of this communication, there are more uncertainties related to my privacy. I understand that if I become uncomfortable with any of these limitations of Telerehab, that I have the right to terminate the session at any time. Further, I understand that Telerehab is not the same as in-‐person healthcare services and if the exercise therapist feels that I would be a better candidate for in-‐person sessions that I may be requested by my clinician to attend such sessions at an appropriate location and that that is my choice. I understand that I will be provided with remote monitoring devices as part of the program and 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 am aware that my readings will be transmitted from RPM device(s) to a software platform in a safe and secure manner.
3. Benefits to Be Expected
I understand that this medical treatment may or may not benefit my health status or physical fitness. Generally, participation will help determine what recreational and occupational activities I can safely and comfortably perform at home or on my own. Many individuals in such programs also show improvements in their capacity for physical work. For those who are overweight and able to follow the physician and exercise physiologist’s recommended dietary plan, this program may also aid in achieving appropriate weight reduction and control.
4. Confidentiality and Use of Information
Confidentiality protections under federal and state law apply to information used or disclosed during Telerehab. I understand that Medical Group may collect, use and disclose my personal information and my personal health information for purposes of:
1. Assessing, treating or providing other health related services by using virtual internet or telephone communication strategies (Telerehab).
2. Providing treatment outcomes and identifying future rehab services that may be provided.
3. Enabling an insurer or funder to determine any potential funding coverage further to my claim.
4. Seeking payment for the services I received.
5. As more fully described in the Medical Group’s Notice of Privacy Practices.
6. If people are close to you, they may hear something you did not want them to know. You should be in a private place, so other people cannot hear you.
7. Your provider will tell you if someone else from their office can hear or see you.
8. We use telehealth technology that is designed to protect your privacy.
9. If you use the Internet for telehealth, use a network that is private and secure.
10. There is a very small chance that someone could use technology to hear or see your telehealth visit.
For quality assurance, training, and program improvement purposes, some telehealth sessions may be monitored and/or recorded. We may also use secure automated transcription tools, including artificial intelligence (“AI”) technology, to assist in creating and maintaining accurate clinical documentation. Recordings and transcripts will be stored securely in accordance with HIPAA and applicable state privacy laws and will only be accessed by authorized personnel. If you do not wish to have your session recorded or monitored, please contact your clinician prior to your scheduled session so that alternative arrangements can be made.
I authorize my Telerehab Provider and its authorized agents to use or disclose my personal information and my personal health information to any other parties involved in my healthcare as reasonably required. Such parties may include a physician, another healthcare provider, an additional member of Medical Group’s treatment team, relevant funders or payors, referral sources or my employer if it relates to the demands of my job, my functional ability or my ability to return to work. I have been informed that the information obtained from this rehabilitation program will be treated as privileged and confidential and will consequently not be released or revealed to any person without my express written consent. I do, however, agree to the use of any information for research and statistical purposes as long as it does not identify my person or provide facts that could lead to my identification. I agree that Medical Group may use my email address and other contact information as a means of providing me information regarding my healthcare, including Telerehab, exercise progressions, appointment bookings and account notifications.
5. Insurance / Medicare
I authorize Medical Group to file for insurance benefits to pay for the care I receive. I understand that Medical Group will send my medical information to my insurance company. I must pay my share of the costs. I must pay for the cost of the care I receive if my insurance company does not pay or I do not have insurance. I understand that I have the right to say no to any treatment or procedure. I have the right to discuss all medical treatments with my provider. I have the right to ask about costs before I am treated.
Insurance covers the rehabilitation services for certain indications and each insurance company has its own set of coverage criteria. You should discuss coverage with your insurance provider.
6. Acknowledgement
I acknowledge that I have read this consent in its entirety. I further understand that there are remote risks other than those previously described that may be associated with this program. Despite the fact that a complete accounting of all remote risks is not entirely possible, I am satisfied with the review of these risks that was provided to me, and it is still my desire to participate.
7. Medical Records Release Consent
I authorize the release of the items below (if applicable). I understand these records will only be used to aid in my treatment, and will not be released to any person or agency without my authorization:
- Most recent doctor's note
- EKG, echocardiogram, stress test and catheterization report
- GOLD grouping, 6MWT, spirometry, DLCO, and other relevant pulmonary function testing
- Discharge summary
- Medical history, including medication list
8. SMS Communications Consent
I agree to receive communications by text message related to the care I receive, and customer care for appointment reminders and billing notifications. I understand that I may opt-out by replying STOP or reply HELP to receive more information. Message frequency varies. Message and data rates may apply. I acknowledge I have received, read, and agree to our Privacy Policy to learn how my data is used.
Release Consent
I consent to participate in Medical Group’s program via telehealth.
I have read this document carefully, understand the potential limitations and risks of receiving services via telerehab, and have had my questions answered to my satisfaction. I also acknowledge I have received, read and agree to the Terms of Service, Privacy Policy, Consent Terms, and Notice of Privacy Practices.
