PRIME Patient Consent & Participation Agreement

PRIME Patient Consent & Participation Agreement

 

I consent to participate in SurgicalRx-supported remote therapeutic monitoring and musculoskeletal health services ordered by my healthcare provider. These services may include:

• Onboarding, education, and symptom/function check-ins
• Activity or exercise adherence tracking and therapy-response monitoring
• Nutrition guidance and protocol support
• Patient communication and reporting to my ordering/billing healthcare practice

I have been informed of the availability of these services and understand that only one practitioner or practice may provide and bill for care management services during any given calendar month.

I understand that SurgicalRx helps collect, organize, monitor, and report information related to my participation. My ordering/billing healthcare practice remains responsible for my medical care, treatment decisions, surgical instructions where applicable, billing decisions, and insurance claims. SurgicalRx does not replace my surgeon, physician, physical therapist, or other licensed healthcare provider.

I authorize SurgicalRx and my healthcare practice to exchange information related to my services, including referral information, intake responses, symptoms, functional status, participation, adherence, therapy response, communications, and related reports, for purposes of treatment, care coordination, billing support, and quality improvement.

I agree that SurgicalRx and/or my healthcare practice may contact me by phone, text, email, app notification, or patient portal. Standard message and data rates may apply. I may opt out of text messages by replying STOP, but doing so may limit my ability to participate in remote monitoring.

I understand this program is not for emergencies. For urgent symptoms — including chest pain, shortness of breath, signs of infection or blood clot, severe pain, a fall with injury, or new neurologic symptoms — I should call 911 or contact my healthcare provider directly.

Regarding billing and cost-sharing, I understand:

• My healthcare practice may bill Medicare, Medicare Advantage, commercial insurance, or another payer for RTM, CCM, or related services
• I may be responsible for copays, coinsurance, or deductibles
• Insurance coverage is not guaranteed
• I have the right to stop services at any time, effective at the end of the current calendar month

Pilot Program Notice. I understand that I am enrolling during an introductory pilot phase of the SurgicalRx PRIME program. During this pilot, I will not be charged any out-of-pocket fees by SurgicalRx regardless of insurance status. While my healthcare practice may submit claims for applicable services, I will not be billed directly by SurgicalRx. This no-cost commitment applies only to the current pilot period and may change in future phases, of which I will be notified in advance. Participation is voluntary with no guaranteed outcomes. I may stop at any time by notifying SurgicalRx or my healthcare practice. By signing below, I confirm I have read and understand this form, had the opportunity to ask questions, and accept or decline the services described above.

Questions? Reach out to info@surgicalrx.com