TeleiCare CCM Enrollment

  • TeleiCare CCM Enrollment

  • Please complete this form to enroll in TeleiCare Chronic Care Managment services. CCM supports patients with multiple chronic conditions through monthly care coordination. 

    • Patient Information 
    • Date of Birth
       - -
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Chronic Care Eligibility 
    • Which chronic condition (s) apply to you?
    • Do you have two or more chronic conditions expected to last at least 12 months?*
    • Are you currently under the care of a provider for these condition (s)?
    • Have you had any emergency room visits or hospitalizations in the last 12 months?
    • CCM Consent 

    • I understand:


      CCM services help manage my chronic conditions between office visits
      My care team may contact me by phone, secure message, or other methods
      Only one provider may bill CCM services per month
      My insurance may be billed monthly for these services
      I may be responsible for copays, coinsurance, or deductibles
      I may withdraw at any time by notifying the clinic

    • Do you consent to participate in the CCM program?*

    • Care Plan Acknowledgement 

      I understand that a personalized care plan may be developed and maintained for me as part of CCM services. 

       

    • Do you agree to care coordination and care plan support?*
    • Billing Authorization 

    • I authorize TeleiCare and affiliated providers to bill my insurance for CCM services. 

    • Do you authorize billing for CCM services?*
    • HIPPA Acknowledgment 

    • I acknowledge that my health information will be handled in accordance with HIPPA. 

    • Do you acknowledge HIPPA policies?*
    • Withdrawal From Program Acknowledgment 

    • I understand that participation in TeleiCare Chronic Care Management (CCM) services is voluntary.

      I understand that:

      • I may withdraw from the program(s) at any time by notifying TeleiCare or my healthcare provider
      • Withdrawal may result in discontinuation of monitoring, care coordination, and related services
      • If I am enrolled in RPM, I may be required to return any monitoring equipment provided
      • Discontinuation of services may impact my ongoing care and provider’s ability to monitor my condition remotely

      By agreeing below, I acknowledge that I understand my right to withdraw from the program at any time.

    • Do you understand that you may withdraw from the program at any time?*
  • Should be Empty: