General Consent & Chronic Care Management Agreement

PATIENT: You have the right, as a patient, to be informed about your condition and the recommended exercise treatment plan to be used to ensure the comfortability of your right to decision on the handling of your care. Please note: All exercise treatment plans are a recommendation to help you achieve and/or improve your living, health conditions. Each plan is a customized based on your medical condition, mediations, and abilities to perform. We cannot guarantee betterment of your health but, we can guarantee our integrity, honesty, transparency, professionalism, and respect. We respect your right to refuse our treatment plans, recommendation, and opportunities to help improve existing health conditions. Even if you accept the program, you have the right to discontinue at any given time, without prejudice or harm.

This consent form is simply an effort to obtain your permission to perform the evaluation necessary to identify the appropriate treatment plan for any identified condition(s).

This consent provides us with your permission to perform reasonable and necessary medical examinations, approved authorized testing (i.e. blood pressure checks, EKG, etc...), and custom treatment plans. By signing below, you are indicating that:

(2) You consent to knowing that you can withdraw/discontinue services from the treatment at your free will

(3) You consent to discussion of your progress with your Physician or Appointed Specialist.

You have the right to discuss the treatment plan with your Physician about the purpose, potential risks and benefits of any exercise performed. If you have any concerns regarding treatment, we are happy to speak with you in full detail at your appointment or anytime we are available. Your comfortability and trust is our top priority. We are also happy to speak with your Physician or whoever you authorize to speak on your behalf.

I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents.

Your health is important to Eps on the Go II. Medicare is offering a new benefit for patients with multiple chronic conditions. In alignment with our dedication to keep you as healthy as possible by managing your conditions with a focus of potentially reducing your hospital visits, and urgent care facilities- You are eligible for Chronic Care Management (CCM).

CCM involves managing chronic conditions effectively in partnership between the healthcare team and patient to maintain the best possible overall health and wellness. This includes a non-face-to-face component of care that involves the creation of a patient-centered plan of care, medication monitoring, management of care transitions, electronic care coordination and exchange of health information with other health care providers as necessary, while providing you (and/or your caregiver) access to our care team.

CCM services are only available to patients with two or more chronic conditions. Medicare defines a chronic condition as a condition that is expected to last for at least 12 months.

Benefits of CCM Services include:

• Making sure CCM patients are reminded of their preventive services due such as their annual wellness exams, mammograms, colon rectal screening, influenza vaccine, etc. These reminders can be performed by either the physician or clinical staff.
• Working with CCM patients to discuss new eating habits needed since they have been newly diagnosed with a chronic condition or existing chronic condition
• Reviewing their readings from remote physiologic monitors i.e. glucometer, CGM, blood pressure monitor, oxygen meter etc. to make sure they are in range or alert the physician mid-level and staff if they are not in case a medication change may be needed
• Sharing information with CCM patients to help them stop smoking
  Making sure the specialist notes are all back in the chart for the provider to review prior to the patient coming in for their office visit; Assisting with information sharing among providers by coordinating the chronic care program
• Medication reconciliation and update provider if there are changes or refills needed
• Reviewing any new herbals or OTCs the patient is taking and notifying the provider to confirm if there are any interactions with their existing medications
• Seeing if a patient needs any qualified medical equipment such as a wheelchair or walker

Beneficiary Acknowledgment and Agreement By signing this agreement, you agree to the following terms:

• You consent to your provider providing CCM services to you.
• You certify that your provider has fully explained the scope of CCM services to you
• You acknowledge that only one practitioner can furnish and be paid for CCM services during a calendar month.
• You authorize electronic communication of your medical information between treating providers as part of your care.
• You understand that CCM services are subject to Medicare Co-Insurance, and so you may be billed for a portion of the CCM services.
• You understand that you have the right to terminate CCM services at any time by advising your Clinician. You will receive a written notification of this termination.
• I consent to allow my Advanced Practitioner and their designees to perform CCM on my behalf.

EPS ON THE GO II LLC: PATIENT'S CONSENT FORM

Revised July 2024