VITASIGNS – Verbal Consent

Hi , this is calling on behalf of about your doctor-recommended care management services—things like checking your blood pressure from home (RPM) and monthly care coordination (CCM/PCM).

Here’s the key info:

• These services help your doctor manage your condition between visits. They are not an emergency service. For urgent symptoms, call 911.
• Your doctor’s office bills your insurance for these services; standard coinsurance may apply based on your plan. Billing questions go to the doctor’s office.
• Only one provider can bill you for these services per month.
• You can stop at any time—we’ll end at the close of the calendar month.
• If you receive a home device for RPM, please use it most days; Medicare typically expects about 16 days each 30-day period.

Do you consent to enroll so your doctor’s team can provide these services?

Patient: DOB: MRN (if available):
Date: Time: Phone # used:
Staff obtaining consent: Role:

1. What it is: Ongoing, between-visit management/monitoring from the physician’s practice; not emergency care.
2. Billing basics: Billed by the physician’s practice; standard coinsurance may apply depending on plan.
3. One provider per month: Only one practitioner may bill these services monthly.
4. Right to stop: Patient may stop anytime; effective end of calendar month.
5. Care coordination info sharing: Health information may be shared with involved providers to coordinate care.
6. RPM device use (if RPM selected): Patient advised typical Medicare expectation ≈ 16 of 30 days.

I attest I provided the information above, answered questions, and documented the patient’s verbal response accurately.

Signature: Date:

Attach to patient's record by uploading a PDF to HubSpot & HealthArc under patient profile.