Consent for Chronic Care Management (CCM) services.
Unless I opt out below, and if WRMG determines I am eligible to receive CCM services, I hereby consent to receive CCM services. I understand that CCM services are to help me manage my ongoing chronic health conditions, which includes:
- Having access to my care team 24-hours-a-day, 7-days-a-week
- Occasional (about once per month) phone calls, text messages and/or email messages to help identify care needs,
- Care management of my chronic conditions, including scheduling of recommended preventive care services, medication reconciliation, and oversight of my medication management,
- Creation of a comprehensive plan of care for my health issues that is specific to me and in line with my values,
- Management of my care as I move between and among health care providers and settings,
- Coordination with home and community-based providers of clinical services,
- An annual wellness examination.
I will receive a copy of my comprehensive plan of care. I understand that I can stop receiving CCM services at any time by notifying WRMG (effective at the end of a calendar month). Medicare will only pay one physician or health care professional to furnish me CCM services within a given calendar month.
I understand WRMG will bill Medicare for performing the CCM services and that I am responsible for payment of the usual Medicare deductible and coinsurance applied to physician services. WRMG may communicate my medical information to other treating providers as part of the care coordination. This designation is effective as of the date below and remains in effect until revoked by me.