Interested in learning more about our Longevity and Wellness Program?

Simply fill out the form below. 

An Enrollment Specialist will then schedule you with an AGM Medical Group Clinician for a personalized visit.

Mail us on

patients@agmmedgroup.com

© 2025 AGM Medical Group. All rights reserved. Do not duplicate.

Consent form

You have been referred to AGM Medical Group, P.C., which is offering you enrollment in three programs:

Chronic Care Management (CCM), Remote Physiologic Monitoring (RPM), and Evaluation & Management (E&M) clinical services. These programs work together to provide Comprehensive Care Management and physiologic monitoring in addition to the support you receive from your current clinical providers.

By signing below, you acknowledge that you have read, understand, and agree to the information below, which applies regarding telehealth services, including but not limited to RPM, CCM, TCM, and E&M services, and that your name and identity have been correctly identified in communications with AGM Medical Group, P.C. and the clinical/equipment provider who referred you.

I hereby consent to receiving RPM, CCM, and E&M services from AGM Medical Group, P.C. as part of my health evaluation and treatment. I further give AGM Medical Group, P.C. and its providers permission to consult with relevant specialists as needed during the course of my treatment, and I further consent to AGM Medical Group, P.C. and its providers forwarding my medical information to my Primary Care Provider/provider of record or, upon my request, to any other clinical provider. I am providing the foregoing consents based on my understanding of the following:

  1.  During the RPM, CCM, and E&M process, my provider and I will be in different physical locations and my medical and/or health information will be communicated to health care providers at those other physical locations. I may benefit from the use of RPM, CCM, and E&M, but results cannot be guaranteed or assured. Furthermore, the use of RPM, CCM, and E&M technology may present certain risks, such as delays in medical evaluation and treatment due to technological issues, the need to reschedule if the transmitted information is of insufficient quality, or potential failure of security protocols which could cause disclosure of personal information. In addition, I understand a lack of access to my complete medical record could result in adverse drug interactions or other unintended results, and I understand it is my responsibility to share complete and accurate information with my AGM Medical Group, P.C. clinical provider.
  2. AGM Medical Group, P.C.’s RPM, CCM, and E&M services are not used to identify emergency medical conditions or to notify anyone of any emergency medical situation. AGM Medical Group, P.C. will not be monitoring my medical and/or health information on a 24/7 basis, or any set minimum basis. I understand that the RPM, CCM, and E&M services are meant to help AGM Medical Group, P.C. get a more complete picture of my health and wellbeing. AGM Medical Group, P.C. does not provide emergency medical services. I understand that if I am experiencing a medical emergency I may be directed to call 911, and that AGM Medical Group, P.C. is not able to connect me directly to local emergency services. In addition, in the event of a suspected or actual medical emergency, such as chest pain, severe shortness of breath, severe headache or bleeding, I should call 911 or proceed directly to the nearest hospital.

AGM Medical Group, P.C. | (866) 211-9447 | patients@agmmedgroup.com

Chronic Care Management (CCM) Services include:

  1.  Access to clinicians with experience in Obstructive Sleep Apnea, Central Sleep Apnea, sleep medicine, and other respiratory illnesses, as well as other chronic/acute conditions.
  2.  24/7 support from Care Navigators for health-related questions and chronic/acute care needs.
  3.  Monthly (or more frequent) calls with your personal Care Navigator to manage your chronic/acute conditions.
  4. 24/7 support from a Virtual Care Companion to assist in your management of chronic/acute conditions.
  5. Assistance with scheduling and coordinating your care appointments.
  6. Creation and maintenance of your Personal Health Record and Comprehensive Care Plan.
  7. Sharing of your health information updates with your authorized clinical providers.
  8. Access to your electronic health record (EHR) at any time.

Remote Physiologic Monitoring (RPM) Services include:

  1.  Monitoring of physiologic device(s) to collect specific health data, including:
    o Vital signs monitoring devices (e.g., blood pressure, weight, blood glucose) as determined by your healthcare provider.
    o Data from Advanced Homecare-provided PAP (Positive Airway Pressure) machines for sleep apnea or other respiratory conditions.
  2. Automatic transmission of your health data to our secure system for review.
  3. Regular monitoring and interpretation of your health data by our healthcare team.
  4. Ability to make timely adjustments to your care plan based on the data collected.

As the patient you further understand:

  1. You are intended to benefit from RPM services, however results are not guaranteed.
  2. You should not tamper with equipment and could be responsible for damages resulting from tampering.
  3.  Delays in evaluation of transmitted data and/or related treatment may occur due to technological failures of RPM devices.
  4. In rare instances transmitted data may be deemed inadequate and an in-person meeting with a clinical provider may be requested.
  5.  You should only use RPM devices to transmit data from your person, and your RPM devices should never transmit data from an individual other than yourself. You understand that your health care may be impacted if health data from a third party is transmitted. 
  6. RPM devices are not intended for emergency response and readings are not monitored at all times.
  7. In California, RPM services may be considered a telehealth service and this consent is intended to satisfy legal requirements as under Section 2290.5(b) of the Cal. Bus. & Prof. Code.

Evaluation & Management (E&M) Services include:

AGM Medical Group, P.C. | (866) 211-9447 | patients@agmmedgroup.com

  1. Access to clinicians with experience in Family Medicine, Primary Care, Geriatric and Palliative Care, and Chronic Care.
  2.  24/7 support from Care Navigators for health-related questions and primary care needs.
  3. 24/7 support from a clinical provider for telehealth consultations.
  4. 24/7 support from a Virtual Care Companion to assist in your management of health conditions.
  5. Assistance with scheduling and coordinating your care appointments.
  6. Sharing of your health information updates with your authorized clinical providers.
  7. Access to your electronic health record (EHR) at any time.

Additional Program Details:

  1. All three programs are supervised by physicians and aim to support, not replace, your existing clinical provider relationships.
  2. We will bill your insurance separately for CCM, RPM, and E&M services. We will not charge you personally for any co-pays and deductibles.  If you have secondary insurance that covers co-pays and/or deductibles, we will bill that secondary insurance.
  3. For CCM, we bill insurance when we spend at least 20 minutes per month on your care.
  4. For RPM, we bill insurance when we collect and interpret at least 16 days of data per 30 day period or spend 20 minutes per month on your care.
  5. For E&M, we bill insurance when we have completed a telehealth or in-person clinical encounter.
  6. Your co-pay may be covered by secondary insurance plans or supplemental plans such as Medicare Advantage.
Indicate your consent to participate by submitting the below form

By filling this form, you consent to our use and disclosure of your Protected Health Information (PHI) for treatment, payment, and health care operations. You have the right to revoke this consent in writing, signed by you. Such a revocation will not be retroactive.

By submitting this form, I understand and acknowledge that:

  1. I have reviewed the Notice of Privacy Practices.
  2. The Practice requires execution of this consent in order to receive treatment.
  3. Protected Health Information may be disclosed or used for treatment, payment, or healthcare
    operations.
  4.  The Practice reserves the right to change the privacy policy as allowed or required by law.
  5. I may ask to restrict the use of information, but the Practice does not have to agree to those
    restrictions.
  6. I have the right to revoke this consent in writing at any time and all disclosures will cease.
  7. The Practice may phone, email, or send a text to me to confirm appointments.
  8. The Practice may leave a message on my answering machine at home or on my mobile phone.
  9. The Practice may record calls with staff for purposes of quality control and to improve care
    experience.
  10. I authorize the Practice to discuss my medical condition with a member of my family as
    described below:

Additional disclosure of protected health information

By submitting this form, I give my consent for AGM Medical Group, P.C. to access, use, and disclose Protected Health Information (PHI) including data, records, and patient call recordings for purposes of providing treatment, payment, and other related health care services.

This Authorization specifically permits AGM Medical Group, P.C.to use and/or disclose the following information about me, at my request and for the following purposes:

  1. Disclosure to 1 True Health, Inc. (a clinical and administrative partner of AGM Medical Group,
    P.C.) for purposes of providing Chronic Care Management (CCM), Remote Physiologic
    Monitoring (RPM), Evaluation & Management (E&M), and other care management services;
  2. Disclosure to the clinical organization that referred you to AGM Medical Group, P.C. for purposes of providing Chronic Care Management (CCM), Remote Physiologic Monitoring (RPM), Evaluation & Management (E&M), and other care management services;

AGM Medical Group, P.C. | (866) 211-9447 | patients@agmmedgroup.com

I acknowledge that I have had the opportunity to review AGM Medical Group, P.C.’s Notice of Privacy Practices prior to signing this consent. A current Notice of Privacy Practices may be obtained by emailing a written request to shawn.smith@agmmedgroup.com.

I have the right to request that AGM Medical Group, P.C. restrict how it uses or discloses my PHI to provide their services. The Practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.

I may revoke my consent in writing, but understand that AGM Medical Group, P.C. may have already made disclosures in reliance upon my prior consent.

Programs Interested In:

Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed and How you can access this information. Please review it carefully.

At AGM Medical Group, P.C. (the “Practice”), we are committed to protecting your medical information. We create a record of the care and services you receive from our clinicians and clinical
staff. This Notice of Privacy Practices applies to all records of your care generated by the Practice.

Your rights

You have the following rights regarding your Protected Health Information (PHI):

  1.  Request Restrictions: You may ask us to limit the use and disclosure of your PHI.
  2. Request Alternative Communications: You can request that we communicate with you in
    specific ways or locations.
  3.  Inspect and Copy: You can ask to see or get a copy of your medical record and other health
    information.
  4.  Request Amendments: You can ask us to correct health information you think is incorrect or
    incomplete.
  5. Accounting of Disclosures: You can ask for a list of the times we have shared your health
    information.
  6.  Obtain a Copy of this Notice: You can ask for a paper copy of this notice at any time.

How we may use and disclose your information

We may use and disclose your PHI without your written authorization for the following purposes:

  1. For treatment
  2. For payment
  3. For health care operations
  4. As required by law and law enforcement
  5. For public health activities and risks
  6. For health oversight activities
  7. To Coroners, Medical Examiners, and Funeral Directors
  8. For research
  9.  To avoid a serious threat to health or safety
  10. For specialized government functions
  11. For Workers’ Compensation

Other uses and disclosures

Other uses and disclosures of your PHI not described in this notice will be made only with your written authorization. You may revoke such authorization at any time.

AGM Medical Group, P.C. | (866) 211-9447 | patients@agmmedgroup.com

Our responsibilities

We are required by law to:

  1. Maintain the privacy and security of your Protected Health Information
  2. Provide you with this notice of our legal duties and privacy practices
  3. Abide by the terms of this notice
  4. Notify you promptly if a breach occurs that may have compromised the privacy or security of your information

Changes to this notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request and on the AGM Medical Group website.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with our Privacy Officer or with the Secretary of the U.S. Department of Health and Human Services. You will not be penalized for filing a complaint.

Contact information

For more information about our privacy practices, please contact Shawn Smith, Administrative Manager:

shawn.smith@agmmedgroup.com | (866) 211-9447

Effective Date: April 25, 2025

AGM Medical Group, P.C. | (866) 211-9447 | patients@agmmedgroup.com