CCM Consent Form

Medicare covers an additional chronic care management service (CCM) that Community Health Centers of America Provides to our patients that are eligible. CCM involves a combination of:

• Access to a care team, including telephone access and non- face- to- face means of communication care management of chronic conditions, including timely scheduling of all recommended preventive care services, medication reconciliation and oversight of medication management.
• Creation of a comprehensive plan of care for all health issues that is specific to you and congruent with your choices and values.
• Management of care as you move between and among health care providers and setting the following:

Referrals to other health care providers
Follow- up after visits to an emergency department
Follow-up after being discharged from the hospital of other facility
Coordination with home and community-based providers of clinical services.

I understand only my primary care provider will provide this service. I will let my provider, or their staff know if I have entered into a similar agreement with another provider/practice. I understand that Community Health Centers of America will bill my insurance for this service and these services are subject to usual Medicare deductible and coinsurance applied to physician services. I also know I can revoke this agreement at any time in writing. My signature also authorizes my provider to electronically communicate my medical information with other treating providers as part of the care coordination involved in chronic care management services.