A message from your provider
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Your health is very important to me and my staff. Our goals are to:
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Keep you as healthy as possible
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Provide you with the best care
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Keep you out of the hospital
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Minimize the costs and inconvenience of unnecessary visits to doctors, labs, or urgent care facilities.
I encourage you to participate in the Chronic Care Management (CCM) program.
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What are CCM Services?
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Chronic Care Management (CCM) services help manage your health between office visits. The program provides a series of non-face-to-face activities and additional services especially for our CCM patients. For example:
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You will have a dedicated Care Team that is familiar with your conditions
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We actively help you manage all your medications
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We help coordinate your care with your other doctors
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We share your health information only with other authorized providers
Your Care Plan
Your Care Plan includes valuable information that will help you understand your medical conditions. Your Care Plan will help you to be as healthy as possible.
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How much does this cost?
The answer depends on your insurance. Each month, after we provide you with a minimum of 20 minutes of non-face-to-face services, we will bill your insurer(s). Either you or your supplementary insurer may be responsible for any deductible or co-pay.
What if I change my mind?
You may stop this service at any time, for any reason. If you choose to stop the service we will provide it only through the last day of the calendar month of your decision. Your signature is required to end Chronic Care Management services, so please ask my staff for the CCM revocation form.
You can only give CCM consent to one provider at a time. If another physician has offered to provide CCM, you will have to choose which physician is best able to treat and manage all your conditions. Please let me or my staff know if you change your mind, or if you have any questions.
How do I get started?
Signing this Chronic Care Management - Patient Consent Form allows me to begin immediately providing you with CCM services.
Again, I encourage you to sign up for this service.
Your Consent
Copy must be given to Patient and retained by Provider.
