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@@ -38,6 +38,18 @@
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<span>I have the right to withdraw my consent to participate in the RPM program and stop receiving RPM Services at any time by returning the equipment.</span>
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</label>
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+ <label class="d-flex align-items-baseline mb-3">
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+ <div class="mr-2 align-self-stretch" style="padding-top: 2px;"><input type="checkbox" name="rpm-agreement-8" required></div>
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+ <span>I agree to participate in the Chronic Care Management program.</span>
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+ </label>
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+ <label class="d-flex align-items-baseline mb-3">
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+ <div class="mr-2 align-self-stretch" style="padding-top: 2px;"><input type="checkbox" name="rpm-agreement-9" required></div>
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+ <span>I understand that CCM involves a combination of face-to-face and non-face-to-face services to ensure that my healthcare needs are met.</span>
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+ </label>
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+ <label class="d-flex align-items-baseline mb-3">
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+ <div class="mr-2 align-self-stretch" style="padding-top: 2px;"><input type="checkbox" name="rpm-agreement-10" required></div>
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+ <span>I understand that I can revoke my participation in CCM at anytime.</span>
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+ </label>
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</form>
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<?php $patient = $note->client; ?>
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