Remote Care Qualification & Medication Intake Form
Section 1: Condition & Symptom Screening

“Are you currently suffering from or diagnosed with any of the following?”
Condition / Symptom	Yes	No	Service Path (Internal Use)
High Blood Pressure (Hypertension)	[ ]	[ ]	RPM (99454/99445)
Diabetes or High Blood Sugar	[ ]	[ ]	RPM (99454/99445)
Congestive Heart Failure / Heart Issues	[ ]	[ ]	RPM (99454/99445)
Chronic Back, Neck, or Joint Pain	[ ]	[ ]	RTM (98977)
Arthritis or Limited Mobility	[ ]	[ ]	RTM (98977)
COPD, Asthma, or Shortness of Breath	[ ]	[ ]	RTM (98976)
Do you have 2 or more of these at once?	[ ]	[ ]	CCM (99490)
Section 2: Medication Reconciliation & Requests

This section justifies the "Treatment Management" time and builds the doctor's plan.

1. Current Medications: "What medications are you taking right now? (Include dosage if known)."

    Medication: ____________________________

    Medication: ____________________________

2. New Medication/Refill Request: "Do you need the doctor to order a refill or a new medication for a symptom today?"

    [ ] Refill

    [ ] New Medication Request

3. Reason for Request: "What is the specific reason or symptom for this medication request?" (e.g., 'My pain is worse,' or 'I ran out of my BP pills.')

    Reason: ___________________________________________________

Section 3: Tech & Support Qualification

“To set you up for remote monitoring, we need to confirm:”

    Smartphone: Do you have a smartphone or tablet with internet/data? [ ] Yes [ ] No

    Willingness: Are you willing to use a "smart" scale or blood pressure cuff once a day? [ ] Yes [ ] No

    Support: Do you have a caregiver or family member who helps you with your health? [ ] Yes [ ] No

🎯 How to Use This to "Close" the Prospect

    Identify the Lead: If they check High Blood Pressure, they are an RPM lead. If they check Joint Pain, they are an RTM lead.

    Add Value: If they say they need a refill (Section 2), tell them: "Great, part of our Remote Care program is that we handle those requests for you so you never run out."

    The Pitch: "Since you have [Condition], we can send you a cellular device at no cost to you that sends your data to our team daily so the doctor can adjust your meds in real-time."