Consent Agreement for Provision of Complex Care Management

Grace Health is offering to provide complex care management (CCM) services to you. We are offering you CCM because you have at least 2 long-term, chronic illnesses that put you at risk for serious problems with your health.

CCM includes:

• A plan of care for your health concerns.
• 24-hour access to a registered nurse or health care provider at Grace Health, 7 days aweek, to talk about chronic disease problems.
• Regular review of your medications and health care needs.
• Regular preventative care.
• Extra follow up care after a hospital or emergency room visit.

When providing CCM, your Provider must:

• Tell you about all the CCM services that you need to best care for your illnesses.
• Give you a copy of your care plan.
• You have the right to stop CCM at any time, you will be billed for services received during the current month at the end of the month.
• You may stop this agreement by calling a Complex Care Nurse at Grace Health, discussing with your provider or sending a letter to your primary care provider at Grace Health.
• If you request to stop services, we will give you a written notice of cancellation, including the requested end date.

By signing this Agreement:

• You agree to Grace Health providing CCM for you.
• You agree to the sharing of your medical information with other providers that may be involved with your care, including electronic sharing.
• You are aware that only one provider can provide CCM services to you during a month.
• You are aware that cost-sharing applies to CCM services, so you may be billed for small portion of the CCM care, even though you may not have a face-to-face visit with yourprovider.
• You agree to participate in your personalized plan of care created by you and your provider.
• You are aware that you may be discharged from CCM services if you no show 3 appointments, do not participate in the plan of care, or cancel appointments resulting in not being seen within 6 months.