New 2024 intake forms

Ph. 262-421-5133

Fx. 262-735-0723

Info@CedarMedGroup.com
Medical Information Release Authroization

I authorize Lily Medical Group to Release my personal health information to insurance companies and health care professionals for the purpose of treatment, payment and other healthcare related options.
Assignment of Benefits & Financial Responsibility Consent
I request that any payment of authorization insurance benefits be made directly to Lily Medical Group

I further agree to assume financial responsibility for all claims due to Lily Medical Group by my insurance. If my primary, secondary and/or tertiary insurance coverage changes or if payment/coverge is denied. I understand that I am financially responsible for any amount not covered.
Patient's name:
Date

MonthDayYear
Date
Patient or Patient Representative's Signature:

Clear
Relationship to patient:

Patient Info

Insurance and Billing Information
Patient Name:
Date of Birth:

MonthDayYear
Date
Place of Residents ( Name of Facility)
Room #
Patient Code Status:

DNRFull Code
Patient POA/ Guardian status:

ActivatedNo
Social Security Number:
Medicare ID#:
Medicaid ID#:
Primary Plan: (advantage plan)
Policy ID #:
Secondary Plan: (supplement plan)
Policy ID# :
Health Care Power of Attorney:

Self; I make my own medical decisionsActivate POA/ Guardian: (if activated POA please fill out below)
Name:
Relationship to Patient
Primary Phone #
Secondary Phone #
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email address:
Billing Contact:

Self; send bills to facility addressFinancial Guarantor (if financial guarantor please fill out below)
Name:
Relationship to Patient:
Primary Phone #:
Secondary Phone #:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address:

Chronic Care Management Program
Dear Patient,

As a patient with two or more chronic conditions, you may benefit from a new Medicare program that Lily Medical Group is offering to all patients. Our goal is to make sure you get the best care possible from everyone that is involved with your care. We can help coordinate your visits with other doctors facilities, labs, radiology, or other testing; We can talk to you on the phone about your symptoms, we can help you with your management of your medication and we provide you with a comprehensive care plan. Medicare will allow us to bill you for the services during any month that we provide at least 20 minutes of non-face-to-face care of you and your conditions. You must provide your consent to participate once a year.

Your assigned clinician incharge of your care is Dr. Kelly Darmody / Dr. Aron Adkins. Sometimes other staff from your practice will talk to you or handle issues related to care but please know that your assigned clinician will supervise all care provided by our staff or clinician who may be involved in your care.

You agree and consent to the following:

As needed, we will share your health information electronically with others involved in your care. Please rest assured that we continue comply with all laws related to the privacy security of your health information.

We will bill Medicare part B, or your advantage plan, for this chronic care management for you once a month. The fee for the services by Medicare is $59.7, of which your portion may very depending on if you have supplement insurance plan, (possibly zero dollars with some plans please verify with your supplement insurance company by calling the number on the back of your card) although you may or may not come into the office every month the account will reflect this charge and you will be responsible for payment. Our office will have a record of our time spent managing your care if you have ever have questions provided each month.

Only one physician can bill for the service for you. Please let us know if another physician has offered to provide you with the service, please let physician or our staff know if you're entered into some agreement with another physician/practice

You have the right to:

A comprehensive care plan from our practice to help you understand how to care for your conditions so that you can be as healthy as possible.

Discontinue the service at any time for any reason. Because your signature is required to end your chronic care management services, please ask our staff member for the CCM termination form.

Our goal to provide you with the best possible care possible, to keep you out of the hospital and minimize cause an inconvenience to you due to our unnecessary visit to doctors emergency room, labs or hospitals we know your time and your health is valuable and we hope that you will consider participation in the program with our practice.
I agree to participate in the Chronic Care Management program

YesNo
Patient/ Pt representative Signature

Clear
Date

MonthDayYear
Date

HIPAA Compliance Patient Consent Form

Our Notice of Privacy Practices Provides information about how we may use or disclose protective health information.

The notice contains a patient's right section, describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent.

The terms of the notice may change, if so, you may be notified at your next visit to update your signature/date.

You have the right to restrict how your protected and health information is used and disclose for treatment, payment, or healthcare operations. We are not required to agree with these restrictions, but if we do, we shall honor this agreement. HIPAA (Health Insurance Probability and Accountability Act of 1996) law allows for the use of permission for treatment payment, or healthcare operations.

By signing this form you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.

By signing this form, I understand that:
- Protected health information may disclose or use for treatment, payment, or healthcare operations
- The practice reserves are right to change the privacy policy is allowed by law
- The patient has a right to restrict the use of the information by the practice. The practice does not have to agree to those restrictions.
- The patient has a right to revoke this consent in writing at any time and all full disclosures will be then cease.
- The practice may condition received of treatment upon execution of this consent.

	Yes	No
May we phone, email or send text to you to confirm appointments?
May we leave a message on your answering machine at home or on your cell phone?
May we discuss your medical condition with any member of your family?

If YES, please name members allowed:
This consent was signed by:
Patient or Patient Representative Signature:

Clear
Date

MonthDayYear
Date
Witness:

Clear
Date

MonthDayYear
Date

Lily Medical Group - Patient Portal Consent to use

Lily Medical Group is offering this secure, HIPAA compliant communication tool as a courtesy to our patients and their families. It is an optional service and we reserve the right to suspend or terminate it at any time. We will alert you to any changes as promptly as possible. This form is intended to inform you of the facts and risks surrounding the use of the web portal. By signing below, you confirm that you have read, understand and agree to comply with our procedures and guidelines for using the patient portal. You also agree not to hold Lily Medical Group or any of their staff liable for network infractions beyond their control. The web portal or webpage has a secure tunnel connection with our clinic that uses encryption to keep unauthorized persons from being able to access and read your health information or your communications to us. To help ensure that the tunnel remains secure, we need to have your current (private) email address and be informed if it ever changes. Keep your portal user ID and password secure so that only you, or someone authorized by you, can gain access to patient information. If you think someone has learned your password, immediately go to the portal site and change it. Your email address is confidential and protected information. With our best effort we will protect this information as we do your medical and personal information. We will never purposefully share this information with any third party. All access to our internal network and electronic medical records (EMR) is password protected. Additionally, in compliance with HIPAA guidelines, our EMR automatically logs the user out after a period of inactivity. Similar to phone communications, messages may be read and addressed by different CMG staff. When your provider is ill or on vacation, your emails will be addressed by a covering provider.
Confidential Email, please print clearly
example@example.com
Patient Name
Date of Birth

MonthDayYear
Date
Print name of POA / Guardian requesting access
Patient or Patient Representative Signature

Clear
Date

MonthDayYear
Date

Medical Information Release Authroization

Assignment of Benefits & Financial Responsibility Consent

Patient Info

Chronic Care Management Program