Est. Completion Time: 60 to 90 Seconds
Please select the conditions you are currently managing and provide today's reading if applicable.
This helps us coordinate your care with your other doctors.
This section helps the doctor update your treatment plan and justifies your Telehealth benefits.
Please check all three boxes to authorize your care:
Select the ONE status that applies to you:
Per CMS regulations, my co-pays for these Telehealth and monitoring services are automatically waived.
Under penalty of law, I certify my annual household income is below $40,800. I understand my co-pay is waived while I am under this threshold. I agree to notify the provider if my income increases, at which point a $20/month co-pay may apply.