RPM-One Inc. Consent Form

INFORMED CONSENT FOR DRIVE HEALTH SERVICES AND COMMUNICATIONS

Introduction: Drive Health, in partnership with your healthcare provider, offers the Drive Health app and Nurse Clara, a digital health assistant designed to help you manage your health more effectively. By signing this consent form, you agree to use the Drive Health app and receive support from Nurse Clara through the app, phone calls, and occasionally SMS messaging.

Purpose of Nurse Clara:

• Who is Nurse Clara? Nurse Clara is a digital assistant designed to assist you with managing your health by providing reminders, health assessments, and personalized health information.
• What will Nurse Clara do?

• Communicate primarily through the Drive Health app and phone calls to provide reminders, check in on your health, and offer support.

• Call you for reminders, health check-ins, or to ask how you are feeling.

• Be available for questions or support through the Drive Health app or phone.

• Very rarely, Nurse Clara may use SMS for communication if necessary.

Consent and Communication: By signing below, you consent to:

• Allow your healthcare provider to share your necessary health information with Drive Health.
• Use the Drive Health app to manage your health information and interact with Nurse Clara.
• Receive communications from Nurse Clara primarily via the app and phone calls, with rare use of SMS messaging. Standard messaging rates may apply, and you can opt out of SMS messages at any time by replying STOP to any message.

Health Records and Privacy:

• The Drive Health app will securely access and store your health records.
• Drive Health will create a personalized knowledge base from your health records to provide accurate and personalized support via Nurse Clara.
• All your health information will be handled in accordance with HIPAA regulations and Drive Health’s privacy policies to ensure your data remains secure and confidential.

Anticipated Benefits and Use of Services:

• The Drive Health app and Nurse Clara aim to improve your access to care, allowing you to manage your health conveniently from home. You can expect personalized assistance with reminders, health tips, and assessments tailored to your needs.
• While the Drive Health app and Nurse Clara strive to provide timely and practical support, there may be occasional technical issues or delays outside our control. Additionally, security measures are in place to protect your data, although no system can guarantee absolute protection against very rare breaches.

Informed Consent Agreement: By signing this form, you acknowledge that you understand and agree with the following:

• I hereby consent to receive services from Drive Health and communications from Nurse Clara as part of my care with my healthcare provider.
• I understand that federal and state law requires healthcare providers to protect the privacy and security of health information. My provider and Drive Health will ensure that my health information is not seen by anyone who should not see it by standard practices.
• I understand that services may involve electronic communication or monitoring of my personal medical information to or by other health practitioners or clinical staff who may be located in another area.
• I understand I have the right to withhold or withdraw my consent to Drive Health services and communications without affecting my right to future care or treatment. I may suspend or terminate these services at any time for any reason or no reason.
• I understand that if I am experiencing a medical emergency, I will be directed to dial 9-1-1 immediately, as my provider and Drive Health’s clinical staff cannot connect me directly to any local emergency service.
• I understand that while I may expect the anticipated benefits from using Drive Health and communications from Nurse Clara in my care, no results can be guaranteed or assured.

Patient Acknowledgment: I acknowledge that I have read and understand the information provided in this consent form. I agree to participate in the Drive Health program and allow Nurse Clara to assist me with my health management.

Patient Signature: ______________________________

Date: _____________________

Printed Name: __________________________