I request and authorize medical care as my physician, his assistant or designees (collectively called “the physicians”) may deem necessary or advisable. This care may include, but is not limited to, routine diagnostics, radiology and laboratory procedures, administration of routine drugs, biological and other therapeutics, and routine medical and nursing care. I authorize my physician(s) to perform other additional or extended services in emergency situations if it may be necessary or advisable in order to preserve my life or health. I understand that my (the patient) care is directed by my physician(s) and that other personnel render care and services to me (the patient) according to the physicians(s) instructions.
• I am aware that the practice of medicine and surgery is not an exact science and I acknowledge that no guarantees have been made with respect to results of suchdiagnostic procedure or treatment.
• I understand that samples of body fluids and/or tissues may be withdrawn from me (the patient) during routine diagnostic procedures. I authorize WESTERN RESERVE MEDICAL GROUP (MILLS MEDICAL PRACTICES) to dispose of those bodily fluids.
• I have been informed and understand that an HIV (human immunodeficiency virus-AIDS) test may be performed on me without my consent if a health professional or Western Reserve Medical Group employee or First Responder sustains exposure to my blood or other body fluid.
By signing this, I agree to receive services provided by Western Reserve Medical Group/ Mills Medical Practices.
I also acknowledge that I have received a copy of the Western Reserve Medical Group Notice of Privacy Practices.
We are a Medicare Participating ProviderMy signature and date below affirms and authorizes each of the following:
1. Medical care deemed necessary or advisable by Western ReserveMedical Group (Mills Medical Practices) Physicians, Nurse Practitioners,and Physician Assistants.
2. Direct billing to Medicare, Medicare Supplement or other insurance on mybehalf.
3. Release of my medical information to my insurance provider and their agents
4. Western Reserve Medical Group and/or any of their corporate affiliatesto obtain medical or other information necessary in order to process claim(s), including determining eligibility and seeking reimbursement for medical supplies and/or medications provided.
5. I acknowledge that I have received a copy of Western Reserve Medical Groups Notice of Privacy Practices.
Please sign date and return this form as soon as possible in order for us to provide medical care and bill Medicare and/or other insurance for your medical care, medical supplies and/or medications
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 youbecause 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 ensureyou 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 timelyreceive 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 specificservices 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:
You have the right to stop CCM Services by revoking this Agreement at the end of a calendar month. You may revoke this agreement verbally or in writing by notifying Provider or care team member.
We believe that this new Medicare benefit can provide significant value to our patients and we appreciate your consideration.
I hereby authorize the following provider to disclose the above-named individual’s health information. I understand that the information in my health record may include information relating to communicable disease, Acquired Immunodeficiency Syndrome(AIDS), or Human Immunodeficiency Virus (HIV), genetic testing or screening, behavioral or mental health, alcohol/drug (substance) abuse or any such related information.
Provider to whom this information will be released:
Western Reserve Medical Group26110 Emery Road, Suite 300Warrensville Heights, Ohio 44128
Purpose of Disclosure:
By signing this authorization, I agree to the following
> I understand if I authorize my information to be released to persons or organizations not subject to federal privacy laws, the information may be re-disclosed by the recipient and the information will no longer be protected.
> I understand that authorizing the use and disclosure of this health information is voluntary and that I can refuse to sign this authorization. I do not need to sign this form in order to receive treatment.
> I understand that I may inspect a copy of the information to be used or disclosed.
> I understand that I can revoke this authorization at any time by contacting my provider, but any revocation will not apply to the extent that my provider has acted in reliance of this authorization.
> I authorize the use and disclosure of my health information as described above. This authorization expires one year from the date on which it was signed, unless otherwise specified.