Consent for Chronic Care Management Services
As a patient with two or more chronic conditions, you may benefit from a new Medicare benefit called Chronic Care Management (CCM) and Behavioral Health Integration that (BHI) we are now offering. CCM/BHI Services are available to you
because you have: 1) been diagnosed with two or more chronic conditions expected to last at least 12 months, and which place you at significant risk of decline and or 2) been diagnosed with one or more behavioral health conditions. Our goal is to ensure
you get the best care possible, to keep you out of the hospital, and to minimize costs and inconvenience to you due to unnecessary visits to doctors, emergency room visits, laboratory testing, or hospital admissions.
By signing this Agreement, you consent to, providing chronic care management and/or behavioral health services (referred to as “CCM / BHI Services”) to you as more fully described below.
• CCM/BHI Services include 24-hours-a-day, 7-days-a-week access to a health care provider in Provider’s practice to address acute needs; a systematic assessment of your health and behavioral health care needs; processes to assure that you timely
receive preventative care services; medication reviews and oversight; a plan of care covering your health issues; and management of care transitions among health care providers and settings. The Provider will discuss with you the specific
services that will be available to you and how to access those services.
Provider’s Obligations. When providing CCM/BHI Services, the Provider must:
• Explain to you (and your caregiver, if applicable), and offer to you, all the Services that are applicable to your conditions.
• Provide a copy of the CCM/BHI care plan to you according to your preference specified below.
Beneficiary Acknowledgement and Authorization. By signing this agreement, you agree to the following:
• You consent to the Provider providing CCM/BHI Services to you.
• You authorize electronic communication of your medical information with other treating providers as part of the coordination of your care.
• You opt in to receiving occasional (estimated frequency is one per month) text messages and/or email messages to help identify care needs you may have and to help your provider align resources.
• You acknowledge that only one practitioner can furnish CCM/BHI Services to you during a calendar month.
• You understand that cost sharing will apply to these Services, so you may be billed for a portion of the Services even though Services will not involve a face-to-face meeting with the provider.
Beneficiary Rights. You have the following rights with respect to CCM Services: