Thank you for your continued interest in ArtemisCare products! Please provide your information so that we can contact you to begin the onboarding process. Contact UsFirst Name *Middle NameLast Name *Gender *Select GenderMaleFemaleOtherUnknownUnspecifiedBirthdate *Email Address *Phone *Street Address *Apartment, suite, etc.City *State *StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWest VirginiaWisconsinWyomingDistrict of ColumbiaAmerican SamoaGuamNorthern Mariana IslandsPuerto RicoU.S. Virgin IslandsZip Code *Time Zone *America/New_YorkAmerica/New_YorkAmerica/ChicagoAmerica/PhoenixAmerica/Los_AngelesAmerica/AnchorageAmerica/HonoluluProduct *Please select the ArtemisCare product(s) you are interested ineCare4YoueVialOfLife (Base)eVialOfLife (with Nursing Add-Ons)SafetyPlus (Base)SafetyPlus (with Nursing Add-Ons)CommunicationVoice4LifePrivacy / Terms and Conditions *Yes, I agree with the privacy policy and terms and conditions.Write a message (optional)HIPAA Consent FormThis document is the informed HIPAA consent to use the eCare4You solution and any add-ons either on your own or through participation in Remote Monitoring programs offered by Artemis Care Inc. or their affiliates and partners utilizing Artemis Care Inc.’s ArtemisCare platform and solutions. By checking the box for HIPAA consent in the eCare4You Mobile app, portal or website, you acknowledge and accept the following: I understand that remote monitoring is not a substitute for emergency care provisioning. The participants and their caregivers understand and acknowledge that they will call 911 if they need emergency medical care or are so instructed by their care providers. I have read and understood the information about remote patient monitoring, as provided in the Information Sheet provided by the program manager if the eCare4You solution and any applicable add-ons are being used as part of a remote monitoring program. I acknowledge that I have the support phone number and email that I can use at any time to ask questions about my participation for any remote health monitoring program utilizing eCare4You. I voluntarily agree to use the eCare4You application and/or participate in remote patient monitoring that utilizes eCare4You application and Artemis Care platform. I understand I can withdraw at any time from the remote monitoring program or cancel my subscription to eCare4You without giving reasons and that I will not be penalized for withdrawing nor will I be questioned on why I have withdrawn. I understand that Artemis Care Inc., their affiliates and partners will have access to my health data as generated in the platform, through mechanisms such as contactless scan, surveys and other means, or imported into the platform from external sources such as electronic health records from my doctors or Health Information Exchanges. I understand and accept that this data will be used by Artemis Care Inc. and their affiliates and partners to solely provide services to me and the data will not be sold, utilized for any non-health related purposes or distributed to anyone without my permission. My health data will be kept as secure as possible per the provisions of the HIPAA law and any security breaches will be brought to my attention within a reasonable time and reasonable attempts to remediate will be made. Data can only be used in a fully anonymized and/or aggregated form for research, publications, sharing and archiving such that this use benefits me or others in receiving better service or better healthcare. I understand that other health provider organizations that will be involved in my care will have access to this data only if they agree to preserve the confidentiality of the data and if they agree to the terms I have specified in this form. I understand that Artemis Care Inc. and their employees and contractors, will have access to this data as provider of the platform but will not use that data for any purpose other than improving the quality of their solution and enabling appropriate care provisioning. In the event this use of the Artemis Care Platform or eCare4You solutions is for pilot or research projects, I understand what I have said or written as part of this health monitoring will be used in reports, publications, and other research outputs by the conducting organization(s) so that anything I have contributed can be recognised. I understand that I need to reach out to the program managers of such projects and not Artemis Care Inc. to inform them not to use my name, in case I do not wish my name to be used. I understand and agree that my use of the eCare4You solution and participation in any remote monitoring program is strictly voluntary. The eCare4You solution and any remote monitoring programs are complementary to but NOT substitutes for the care provided by your doctors and specialists. I agree not to hold Artemis Care Inc. and its employees, contactors, affiliates and partners liable or seek indemnity for any errors, omissions or technological issues in delivering service. Signature *By electronically signing this form I am providing my consent, I confirm that I have read this form and ensured that I fully understand this information.Start signing your signature hereYour browser does not support e-Signature field.SubmitSave as Draft Download eCare4You If you have not done so already, please download the eCare4You Mobile App, available in the App Store and Android Play Store! Take Charge of Your Well-being: Discover eCare4You Today.