Chronic Care Management (CCM) Consent Form

Agreement to Receive Chronic Care Management ServicesHealth Empowerment Network of Maryland, Inc.

You may benefit from our Chronic Care Management (CCM) services as a patient with two or more chronic health conditions. These services are designed to support you in managing your health more effectively and help you achieve your healthcare goals.

Overview of Chronic Care Management Services

By enrolling in this program, you will receive ongoing support from our care team to help manage your chronic conditions. The services provided include:

• Care Coordination: Assistance with managing your health conditions, including scheduling appointments for preventive care and helping you understand your medications.
• 24/7 Access: For health concerns or questions, you can access your care team by phone, email, and through your electronic health record, available 24 hours a day, 7 days a week.
• Consistent Care: When you visit our health center, we strive to have you see the same provider or care team members whenever possible to ensure continuity of care.
• Personalized Care Plan: Create a customized care plan tailored to your health needs, goals, and preferences.
• Care Coordination Across Providers: We will work with other healthcare providers(such as specialists, hospitals, or emergency departments) to coordinate your care and ensure all aspects of your health are addressed.

Your Rights and Participation in the Program

• Care Plan: You will receive a copy of your personalized care plan to ensure you are informed and involved in your care decisions.
• Right to Discontinue Services: You may choose to stop participating in the ChronicCare Management program anytime. Your decision will take effect at the end of the current calendar month. To stop participation, don't hesitate to contact our office.
• Billing and Payment:

• By signing this consent form, you agree to allow Health Empowerment Network of Maryland to bill Medicare for CCM services provided to you. These services must meet the requirement of at least 20 minutes of care coordination during a given month.
• Only one healthcare provider or facility can provide and bill for Chronic Care Management services in a given month. Please notify us if you are receiving these services from any other provider SO we can ensure compliance with billing regulations.
• You are responsible for any applicable coinsurance, copayments, or deductibles, which may be billed to you directly. These charges apply even if there is no face-to-face visit with a provider.

Sharing of Health Information: You consent to allow Health Empowerment Network of Maryland to share your health information electronically with other providers involved in your care, as needed, to ensure proper coordination and management of your treatment.

Your Consent

By signing below, you acknowledge that you understand and agree to the following:

1. You consent to receiving Chronic Care Management services from Health Empowerment Network of Maryland, Inc.

2. You agree to allow us to bill Medicare for these services during any month at least 20 minutes of care management services are provided.

3. You understand that only one healthcare provider or facility can provide and bill for CCM services in any given month.

4. You consent to share your health information with other providers for care coordination. If you have any questions or concerns about the services, billing, or your rights under this program, please feel free to ask your care team.

Guardian or Caregiver Information (if applicable): Name:

I have read and understand the information provided above. I consent to participate in the Chronic Care Management program and agree to the terms outlined in this consent form.

Guardian or Caregiver Signature (if applicable): Date:

HENM, Inc. 7610 Pennsylvania Avenue, Suite 103 Forestville, MD 20747 www.henmaryland.org