PHYSICIAN AUTHORIZATION OF PATIENT TO PARTICIPATE IN LORIAN HEALTH WIRELESS HOME MONITORING PROGRAM

Dear Physician,

Lorian Health is offering a new benefit to our home health patients. We have implemented a wireless home monitoring program with the primary goal of decreasing morbidity and mortality as well as preventing hospitalizations among homebound patients by detecting early signs of deterioration and intervening quickly before health status worsens.

We believe your patient , DOB: who was referred to us for home health services would be a good candidate for this program. We are writing to obtain your authorization for this patient to participate in our program, as well as to obtain standing orders that will be used in conjunction with our program. We also request that you send us by fax the patient’s most up-to-date health records, including medication lists, problem lists, relevant diagnostic studies and most recent clinic notes pertaining to the patient’s ongoing health conditions as listed below:

I would like to have access to my patient’s telehealth information. Initial:

Thank you for your cooperation, and we look forward to providing excellent care to your patient!

Sincerely,

Lorian Health Staff

Tel: (877) 567-4265

Fax: (619) 280-8150

Authorization

(physician printed name) authorize my patient: (patient’s name) to participate in Lorian Health’s Wireless Home Monitoring Program, which includes the use of standing orders that I have indicated below on the attached forms.

I,

Signature Date