Welcome to Medivive!
We are honored to be your trusted partner in managing your chronic conditions. This form is designed to gather essential consents and agreements for receiving 100% telehealth-based chronic disease management services through Medivive. We’re here to provide continuous support for Hypertension, Asthma,COPD, Arthritis, and Heart Disease Management, ensuring you receive personalized care to improve your quality of life.
1. Telehealth Consent
I consent to receive chronic disease management services via telehealth (remote video or phone consultations) provided by Medivive. I acknowledge that:
- I will have the same rights and responsibilities as I would in an in-person visit.
- There are potential risks associated with telehealth, including technical failures,
unauthorized access, and limitations to face-to-face interaction. - My healthcare provider will evaluate the appropriateness of telehealth services for my condition and may recommend in-person care if necessary.
- I understand that all telehealth consultations are conducted under the highest privacy and security standards in accordance with applicable regulations. Patient Signature (Telehealth Consent): __________________________________________
Date: ____________________
2. Informed Consent for Chronic Disease Management
Description of Treatment Options:
Medivive offers a variety of chronic disease management services to help you take control of your health. Here’s what we offer and how we can help:
- Hypertension Management:
Benefits: By managing blood pressure, you reduce the risk of heart disease, stroke, and kidney issues. Telehealth offers regular monitoring, ensuring you stay on track.
Risks: Failing to follow prescribed treatments or missing check-ins could increase health risks over time. - Asthma Management:
Benefits: Regular telehealth visits allow us to track your symptoms, adjust medications, and help you avoid asthma attacks. We’re here to support you in breathing easier.
Risks: Non-adherence to inhalers or treatments may lead to uncontrolled symptoms or increased hospitalizations. - COPD Management:
Benefits: Our telehealth team works to keep your COPD in check, minimizing flare-ups and helping you maintain better lung function.
Risks: Failing to follow care plans could lead to worsening symptoms or the need for more intensive treatments. - Arthritis Management:
Benefits: Regular monitoring and therapy recommendations can relieve pain and help you regain mobility. We’ll tailor your treatment to your specific needs.
Risks: Delaying treatment can increase the risk of joint damage and long-term
complications. - Heart Disease Management:
Benefits: Through regular check-ins and personalized plans, we help you manage heart disease and prevent complications like heart attacks or stroke.
Risks: Inconsistent follow-ups or failure to adhere to treatment can increase the risk of serious heart-related issues.
3. Treatment Selection
I am seeking telehealth treatment for the following chronic conditions (please check all that
apply):
- Hypertension Management
- Asthma Management
- COPD Management
- Arthritis Management
- Heart Disease Management
4. Monitoring and Follow-Up Commitment
At Medivive, we believe in the power of ongoing support. Regular follow-ups are essential for us to assess your progress and adjust your care plan to ensure your condition is managed optimally.
- Hypertension Management:
We will monitor your blood pressure closely and adjust medications as necessary to keep it under control. - Asthma and COPD Management:•
Consistent follow-ups help us ensure your breathing remains stable, adjust medications, and offer support in avoiding exacerbations. - Arthritis and Heart Disease Management:
Regular telehealth check-ins allow us to monitor your heart health and joint mobility, ensuring that we are optimizing your quality of life. Patient/Parent/Guardian Signature (Follow-Up Commitment):
__________________________________________
Date: _____________________
5. Medication and Treatment Agreement
I agree to:
- Take prescribed medications as directed by my healthcare provider.
- Follow lifestyle recommendations, such as dietary changes or exercise plans, to improve my condition.
- Attend all scheduled follow-up appointments to receive medication refills and treatment adjustments as needed.
Patient/Parent/Guardian Signature (Medication Agreement):
__________________________________________
Date: _____________________
6. Lab Work and Assessments Consent
For managing chronic conditions, periodic lab work or assessments may be required to ensure
your treatment plan is effective. These may include:
- Blood Tests for heart disease or hypertension
- Lung Function Tests for asthma or COPD
- Other assessments specific to your condition
I understand that: - any necessary changes to my treatment.
- Failure to complete required lab work may impact my treatment plan.
Patient/Parent/Guardian Signature (Lab Consent):
__________________________________________
Date: _____________________
7. Minor Consent for Chronic Disease Management
If the patient is a minor, I, as the parent or legal guardian, provide consent for chronic disease management through Medivive’s telehealth services.
Parent/Guardian Name (Printed): __________________________________________
Relationship to Patient: __________________________________________
Parent/Guardian Signature: __________________________________________
Date: _____________________ _
8. Emergency and Adverse Reactions Instructions
In case of severe health complications, I understand that I should:
- Immediately stop any medication (if applicable).
- Seek assistance from the following condition-specific resources:
Emergency Contacts: - American Heart Association: 1-800-242-8721
- Asthma and Allergy Foundation of America: 1-800-727-8462
- COPD Foundation: 1-866-731-2673
- For life-threatening emergencies, call 911 or go to your nearest emergency room.
9. Financial Agreement
I understand that Medivive is a cash-pay service. I can request a receipt if I wish to seek reimbursement from my insurance provider independently. Patient/Parent/Guardian Signature (Financial Agreement):
__________________________________________
Date: _____________________
10. Patient-Specific Goals
Let us know what health outcomes you’re most eager to achieve with our support:
•
•
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11. Release of Liability
I release Medivive and its healthcare providers from any liability related to my treatment, provided I follow all medical advice and prescribed instructions.
Patient/Parent/Guardian Signature (Liability Release):
__________________________________________
Date: _____________________
12. Educational Information and Trusted Resources
For more information on managing chronic conditions, visit:
- American Heart Association: https://www.heart.org
- Asthma and Allergy Foundation of America: https://www.aafa.org
- COPD Foundation: https://www.copdfoundation.org
- Arthritis Foundation: https://www.arthritis.org
13. Educational Information and Trusted Resources
I confirm that all information provided is accurate, and I understand the terms of my treatment. I look forward to working with Medivive to manage my chronic condition and achieve optimal health.
Patient/Parent/Guardian Signature (Final Consent):
__________________________________________
Date: _____________________
Thank You for Trusting Medivive!
We are proud to partner with you in managing your chronic condition. Together, we’ll work to improve your quality of life and long-term health.
