Remote Health Program Application and Notice

(Please print, sign this document, and submit it to your service provider.)

Welcome to the Remote Health Program, which provides personalized health monitoring and support. To Enroll, Please Complete the Following Steps:

Member Information:

Full Name: _______________________________________

Phone Number: ___________________________________

Email Address: ____________________________________

Authorization for Communication: By signing this form, you authorize our caregivers to contact you via phone calls or text messages regarding your health monitoring, including appointment reminders, missed measurement notifications, and other health-related updates.

 

I hereby authorize ForaCare Inc. to contact me using the above phone number for the purposes of my participation in the Remote Health Program.

 

Signature: _______________________________________

 

Date: ___________________________________________

 

Communication Options:

You will have the ability to reply directly to messages from your caregiver or initiate communication with them if you have any questions or concerns about your care.

 

Right to Withdraw:

Participation in the messaging service and the Remote Health Program is voluntary. You may terminate the communication service or withdraw from the program at any time by providing written notice to ForaCare.

To opt-out, please notify us in writing at service@foracare.com.

Please review this form carefully, sign where indicated, and return it to us to complete your enrollment.

 

Contact Information:

For any questions or further information, please contact us at:

Phone: 888-307-8188

Email: service@foracare.com

Address: 893 Patriot Drive, Suite D, Moorpark, CA 93021

Thank you for your interest in the Remote Health Program. We look forward to supporting you in your health journey.