Explaining Chronic Care Management (CCM) and Behavioral Health Integration (BHI):
If your health care provider (referred to as “Provider”) recommends chronic care management services or behavioral health integration services (BHI) (referred to collectively as “CCM Services”) to you, you agree to the following services as described below. CCM Services will be available to you if you have been diagnosed with two (2) or more chronic conditions which are expected to last at least twelve (12) months and which place you at significant risk of further decline.
CCM Services include 24-hours-a-day, 7-days-a-week access to a health care provider to address acute chronic care needs; systematic assessment of your health care needs; processes to assure that you timely receive preventative care services; medication reviews and oversight; a plan of care covering your health issues; and management of care transitions among health care providers and settings.
The Provider will discuss with you the specific services that will be available to you and how to access those services. Provider’s Obligations. When providing CCM Services, the Provider must:
• Explain to you (and your caregiver, if applicable), and offer to you, all the CCM Services that are applicable to your conditions.
• Provide to you a written or electronic copy of your care plan.
• If you revoke this Agreement, provide you with a written confirmation of the revocation, stating the effective date of the revocation.
Beneficiary Acknowledgment and Authorization.
By signing this Agreement, you agree to the following:
• You consent to the Provider providing CCM Services to you.
• You authorize electronic communication of your medical information with other treating providers as part of coordination of your care.
• You acknowledge that only one practitioner can furnish CCM Services to you during a calendar month.
• You understand that cost-sharing will apply to CCM Services, so you may be billed for a portion of CCM Services even though CCM Services will not involve a face-to-face meeting with the Provider. Beneficiary Rights.
You have the following rights with respect to CCM Services:
• The Provider will provide you with a written or electronic copy of your care plan.
• You have the right to stop CCM Services at any time by revoking this Agreement effective at the end of the then-current month. You may revoke this agreement verbally (by calling Provider's office) or in writing to your Provider's primary business address. Upon receipt of your revocation, the Provider will give you written confirmation (including the effective date) of revocation.
During sign-up you will be assigned an anonymized subject ID number within the system. All utilization of the Lief smart patch, app and program will be linked to your de-identified subject ID.
All physiological data will be collected unobtrusively through continuous passive ECG monitoring, and will not be connected to any identifiable information. The only sensitive data collected is comprised of the GAD-2 and PHQ-2, which includes the self-report of symptoms of anxiety and depression. This data is needed in order to evaluate the effectiveness of the Lief program at improving these core outcome measures in study participants. No identifiable information will be attached to these measures at any time. This is because all study participants will complete these measures within the Lief app, which is only linked to the participant via a subject ID for their protection. The only identifiable information collected will be your name and age (in years, not date of birth). This will be stored in an encrypted and password protected database separate from your other data.
You may be contacted by telephone in the event that the study investigators deem it necessary to do so, for example in the unlikely event that adverse effects are found to occur as a result of this study.
Text Messaging Consent
By signing below, you authorize your Provider to contact you by SMS text message to serve you better. Provider will send me text messages through the Provider member outreach program to help you stay healthy, including:
• timely reminders about needed healthcare visits
• how to get help scheduling healthcare visits
• tips for improving mental wellbeing and reducing stress
• information to help manage chronic illnesses
You understand that message/data rates may apply to messages sent through Provider to my cell phone.
You acknowledge you are under no obligation to authorize Provider to send you text messages as part of this program.
You may opt-out of receiving these communications from Provider at any time by calling your Provider's main office or by texting 'STOP' in response to any text message communication.
Explaining Remote Patient Monitoring (RPM):
If your clinician recommends Remote Patient monitoring (RPM), you agree that:
You are the only person who should be using the remote monitoring equipment as instructed. You will not use the device for reasons other than your own personal health monitoring. You understand that you can only participate in this program with one Medical Provider at a time. You will not tamper with the equipment. You understand that you are responsible for any fees associated with misuse of the equipment. You understand the devices are only designed for the RPM program. You acknowledge that you received a Lief Patch for your remote monitoring services. The device is meant to collect Electrocardiogram (ECG) Readings and transfer those readings to an online dashboard. It is NOT AN EMERGENCY RESPONSE UNIT AND IS NOT MONITORED 24/7. Call 911 for immediate medical emergencies. You are aware your daily ECG readings will be transmitted from the patch to a clinical monitoring dashboard located at www.getlief.com in a safe and secure manner. You acknowledge that cost-sharing may apply to RPM Services, so you may be billed for a portion of RPM Services even though RPM Services will not involve a face-to-face meeting with the Provider. You can withdraw your consent to participate in this program, and revoke service at any time by returning the Lief device.
Your clinician will securely and confidentially store your collected data, and record and store my readings into your clinical record. You will do your best to wear your Lief Patch every day. You are aware that a Remote Patient Monitoring Qualified Health Professional will only view your readings every 30 days, and that this program is NOT a 24/7 Monitoring Service. You may be contacted every 30 days, by phone, to review and discuss your results and progress.
You have read and understood the information and consent to participate in the Remote Patient Monitoring program as stated above. You are aware that this consent is valid as long as you're in possession of the RPM equipment/device.