I request and authorize Western Reserve Medical Group (WRMG) to provide me with medical and other health services that it deems necessary or advisable. This care may include, but is not limited to, routine diagnostics, administration of pharmaceuticals, and routine medical and nursing care. I understand that my care may be provided by a physician and other practitioners.  I am aware that the practice of medicine is not an exact science and that no guarantees have been made with respect to results of any diagnostic procedure or treatment. 

I authorize WRMG to bill my insurance for services received. I authorize WRMG to obtain information necessary to process claims, including determining eligibility and seeking reimbursement for medical supplies and/or medications.  

I understand that samples of body fluids and/or tissues may be withdrawn from me during routine diagnostic procedures. I authorize WRMG to dispose of those bodily fluids.  I understand that an HIV (human immunodeficiency virus) test may be performed on me without my further consent if a health professional is exposed to my blood or other body fluid.

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.

By signing this, I agree to receive medical services from WRMG.

I acknowledge that I have received a copy of the WRMG Notice of Privacy Practices.           

Provider to which information will be released:

Western Reserve Medical Group

26110 Emery Road, Suite 300  Warrensville Heights, OH 44128

Phone: 1-800-807-6555

Fax: 855-453-5010

Purpose of request:

Treatment, continuity of care

Date Range of Information Requested:

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.  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.