The Chronic Care Management (CCM) services that Home Physicians Group will provide me under the agreement include the following:
- Access to my care team 24 hours a day, 7 days per week, for urgent needs, including telephone access and other non-face-to-face means of communication (ie email),
- The ability to get successive, routine appointments with my designated primary care provider or member of my care team,
- Care Management of my chronic conditions, including timely scheduling of all recommended preventative 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 congruent with my choices and values, Management of my care as I move between and among health care providers and settings, including:
- Referrals to other health care providers
- Follow-up after I visit an emergency department
- Follow-up after I am discharged from the hospital or other facility, such as skilled nursing facility
- Coordination with home and community-based providers of clinical services
My signature below indicates my understanding and agreement to receive CCM services and that I understand:
- Home Physicians Group is designated by me for purposes of providing CCM to me and for submitting claims for payment to Medicare and other insurers for the CCM services,
- I will receive a copy of my comprehensive plan of care,
- Home Physicians Group is authorized to electronically communicate my medical information with other treating providers as part of the care coordination involved in CCM services,
- Medicare and other insurers will only pay one professional/practice for CCM services provided to me during a calendar month
- I revoke all previous consent for CCM services prior to this date
- CCM services are subject to the usual Medicare deductible and coinsurance applied to my Medicare Part B services, and I can revoke this agreement at any time (effective at the end of the current calendar month) and can choose to receive these services from another provider or not to receive CCM services at all after the calendar month in which I revoke this agreement.