PHYSICIAN ORDER: REMOTE CARE SERVICES (RPM / RTM / CCM)

Patient Name: __________________________________  DOB: ____________  Date: __________
SECTION 1: CLINICAL INDICATIONS & SERVICE SELECTION

The provider orders the following service(s) based on the patient’s chronic condition(s):
Select Service Path	Qualifying Diagnosis / Clinical Focus	CPT Code Group
☐ RPM (Physiological)	Hypertension, CHF, Diabetes, or Chronic Weight Mgmt.	99453, 99454, 99457
☐ RTM (Musculoskeletal)	Chronic Pain (Back/Neck/Joint), Arthritis, or Mobility Issues.	98975, 98977, 98980
☐ RTM (Respiratory)	COPD, Asthma, or Chronic Bronchitis.	98975, 98976, 98980
☐ CCM (Chronic Care)	2+ Chronic Conditions requiring a comprehensive care plan.	99490, 99439, 99491
SECTION 2: MEDICAL NECESSITY & PLAN OF CARE

I certify that the ordered services are medically necessary for the following clinical goals:

    ☐ Stabilize Physiological Data: Monitor BP/Glucose/Weight to prevent acute exacerbation.

    ☐ Therapy Adherence: Monitor musculoskeletal response and adherence to home exercise/rehab.

    ☐ Medication Management: Monitor respiratory status and inhaler technique/adherence.

    ☐ Care Coordination: Manage complex care needs between multiple specialists/providers.

Primary Diagnosis (ICD-10): ______________________________________________________
SECTION 3: PATIENT CONSENT & ATTESTATION

Staff has confirmed the following with the patient:

    Authorization: Patient consents to remote monitoring and the use of a digital medical device/app.

    Data Privacy: Patient understands data will be transmitted electronically to this clinic.

    Financial Responsibility: Patient is aware that standard co-pays and deductibles apply monthly.

    Engagement: Patient agrees to use the device/app for at least 16 days per month (for RTM/RPM).

Patient/Guardian Signature: ______________________________________ Date: __________
SECTION 4: PROVIDER AUTHORIZATION

    "I hereby order the Remote Care Services checked above. I certify that this patient is under my care and that these services are integral to the treatment of their chronic condition(s). This order remains valid until the patient is discharged from the program or clinical goals are achieved."

Provider Signature: __________________________________________ NPI: _______________

Printed Name: ______________________________________________ Date: _______________