Welcome to Gojji Remote Patient Monitoring (RPM)
Your provider has recommended you for enrollment in the Gojji Remote Patient Monitoring (RPM) program to help manage your health condition(s). This form explains what RPM involves, its benefits and risks, and your rights. Please read carefully and provide your consent below.

What is Remote Patient Monitoring (RPM)?
RPM uses electronic devices to automatically collect and send health data (e.g., blood pressure, heart rate, glucose levels, weight, steps, sleep patterns, or exercise) from your home to your healthcare team. Gojji partners with your provider to provide these services, allowing your care team to monitor your health remotely and adjust your treatment plan as needed. RPM complements—not replaces—care from your primary care provider, who remains responsible for your overall medical care. If you do not have a primary care provider, we strongly encourage you to find one.

Why Am I Being Offered RPM?
Your provider has determined that RPM is medically necessary to monitor your chronic conditions such as hypertension and/or diabetes and improve your care. This recommendation follows an evaluation of your health needs as an established patient of your provider.

Expected Benefits:

• Stay at home while your care team monitors your health remotely.
• Faster detection of health changes, leading to timely care adjustments.
• Improved management of your condition(s) through regular monitoring.

Possible Risks:

• Delays in care due to equipment or technology failures (e.g., device malfunctions or internet/cellular issues).
• Rare cases where transmitted data may not be sufficient, require an in-person visit with your provider.
• Extremely rare instances where security measures fail, potentially risking the privacy of your health information.

Your Responsibilities and Device Use:

• You agree to use the RPM devices (e.g., blood pressure cuff, glucometer) as instructed by your provider or Gojji staff, solely for monitoring your health.
• Use your RPM devices for at least 16 days per month.
• If you experience technical issues, contact Gojji at (909) 693-3376 or your provider for assistance.

Costs and Billing:

• Medicare Part B covers RPM services, but you may be responsible for a copayment, unless covered by supplemental insurance or Medicaid.  Our Gojji staff should have informed you whether you have a copay or not.
• Your health information may be shared with billing staff or others for scheduling and payment purposes.

Privacy and Security:

• Federal and state laws (e.g., HIPAA) require us to protect your health information. Gojji and your provider use secure systems to prevent unauthorized access.
• Your data may be reviewed by clinical staff, including those outside your state, to support your care.

Your Rights:

• You may withhold or withdraw consent for RPM at any time without affecting your future care. To stop RPM services, contact Gojji at (909) 693-3376.
• In a medical emergency, call 9-1-1 immediately—Gojji RPM program  is not intended to address emergency situations.   

Consent and Acknowledgment:

• I consent to receive RPM services as part of my treatment plan ordered by my provider
• My doctor uses remote patient monitoring program to track my diabetes and/or hypertension with a device at home.
• It helps my doctor watch my health so I don’t always need office visits.
• There may be a copay unless I have dual coverage in Medicare and Medicaid.
• I can stop RPM anytime by telling my doctor or Gojji—no problem.
• If it’s an emergency, I’ll call 9-1-1—RPM can’t do that.
• I agree to conduct testing (such as blood pressure test) at least 16 days a month so that my Provider & Gojji can monitor my health condition.
• I agree to have Gojji as part of my care team, helping me to manage my conditions.  I agree Gojji team to contact me via phone and text.