CHRONIC CARE MANAGEMENT (CCM) SERVICES CONSENT FORM

I understand and consent to participate in Chronic

Care Management (CCM) services provided by Olive Health.

Chronic Care Management is a Medicare and insurance-covered service designed to help patients with multiple chronic conditions receive coordinated, comprehensive care

between office visits. CCM services include:

Care Coordination: Regular communication between your healthcare team

Medication Management: Review and monitoring of your medications Health Monitoring: Regular check-ins about your symptoms and conditions Care Plan Development: Creating and updating a personalized care plan 24/7 Access: Access to healthcare providers for urgent questions Specialty Care Coordination: Help managing referrals and specialist appointments

I understand that CCM services may include: Monthly phone calls or secure messaging to discuss my health status Review of my medications and potential interactions Coordination with specialists and other healthcare providers Development and updates to my comprehensive care plan Health education and self-management support 24/7 access to clinical staff for urgent questions Electronic health record management and care coordination

CCM services are typically covered by Medicare and many insurance plans. 

I understand there may be copays or deductibles associated with these services.

I authorize Olive Health to bill my insurance for CCM services

I am responsible for any amounts not covered by insurance.

PATIENT RIGHTS AND RESPONSIBILITIES

I can refuse CCM services at any time without affecting other care I can revoke this consent at any time by contacting the practice Ihave the right to a copy of my care plan I can request changes to my communication preferences

Participate actively in my care management Keep scheduled appointments and respond to outreach attempts Inform the care team of changes in my condition Update contact information when it changes

My health information will be protected according to HIPAA regulations Information may be shared among my care team members for coordination

Electronic communication carries some privacy risks, which have been explained to

I have read and understand this consent form. I have had the opportunity to ask questions about CCM services. I voluntarily consent to participate in Chronic Care Management services. I understand I can withdraw from CCM services at any time