I understand that:

1) I am the only person who should be using the remote monitoring device as instructed. I will not use the device 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. This Medical Provider is RTP Healthy Wellness, PLLC d/b/a Lifestyle Medical Centers.

2) I understand that I must use the device and monitor my readings by stepping on the scale at least four days per week and maintain ongoing two-way communication with my Health Coach and Exercise Physiologist. If I fail to comply with this commitment, I agree to return the scale within 30 days unless Lifestyle Medical Centers determines that less frequent weighing is appropriate.

3) I understand that the cloud-based system will wirelessly upload my data to the manufacturer, and I have given permission to Lifestyle Medical Centers to review that data electronically and remotely in a safe and secure manner and store my readings into my Electronic Medical Record on an on-going basis.

4) I understand that this monitoring program is NOT AN EMERGENCY RESPONSE UNIT AND IS NOT MONITORED 24/7. I understand that I am to call 911 for immediate medical emergencies.

5) I can withdraw my consent to participate in this program, and revoke service at any time.

6) I am aware that my Medical Provider will review my readings multiple times each month, and that this program is NOT A 24/7 monitoring service.

7) I will be contacted by phone, portal message or text message by my Medical Provider to review and discuss my readings/data/values and my progress, and for instructions on possible changes to my treatment plan.

8) I understand that my Medical Provider will bill my health insurance plan for remote patient monitoring services.

(print your name) have read and understood the information and consent to participate in the Remote Patient Monitoring program as stated above.