BrainHealthPlus

Enrollment Form

Complete this information which will be used to enroll you in the BrainHealth+ program.
Provide your name as it appears on your Medicare ID Card.

First Name

Middle Name

Last Name

Select Medicare Plan Type.

I have Medicare only

I have Medicare and a Supplement Plan

I have a Medicare Advantage Plan

Medicare ID Number

Address 1

Address 2

City

State

Zip Code

Email Address

Phone Number

Date of Birth

Biological Sex

Consent:

To the best of my knowledge, I’m not enrolled in any other Remote Therapeutic Monitoring (RTM) program, and by enrolling here, I agree to have my insurance billed for the RTM benefits and services I’m provided. I authorize electronic communication of my medical information between medical providers involved in my care.

I consent to participate in RTM services provided by ConnectHIN and BrainHealth+ and the medical service provider(s) assigned to my care as part of my care team. I understand these services involve the collection and monitoring of my health data related to my diagnosed condition(s). I agree to use BrainHealth+, which is considered a medical device, as part of my care plan, and to participate in communication with my care team.

I understand that standard Medicare and or Medicare Advantage cost-sharing (co-pays) may apply, however, supplemental Medicare, Medicare Advantage, and/or Medicaid coverage may cover all or part of such costs. I understand that I will be alerted as soon as possible if I might have copays and I understand that I may discontinue BrainHealth+ at any time without penalty.

By submitting this form, I consent to receive communications from ConnectHIN, BrainHealth+, which may include information regarding my care, including automated telephone dialing system messages about information/research related to chronic condition management. Data usage rates may apply. I acknowledge that I can opt out of receiving SMS text messages at any time by texting STOP. Email opt out instructions will be provided to me. I will review details provided in the Privacy Policy and Terms and Conditions buttons.

Please click NEXT to complete the required questionnaire and then click SUBMIT on the next page to begin the BrainHealth+ program.

Please read the Consent section and then check the gold Consent box on this page.

*Limitations, copays and restrictions may apply