CHRONIC CARE MANAGEMENT FORM (ONLY for those on Medicare)

 

Consent for Chronic Care Management

  • Colorado Clinic is providing chronic care management services (CCM) to our patients. CCM allows for non face-to-face in between visit care to ensure that each patient’s healthcare needs are met.

    The non face-to-face component of CCM involves the creation of a patient-centered plan of care, medication monitoring, management of care transitions, care coordination and exchange of health information with other health care providers as necessary. I consent to allow my physician, my physician’s assistant or designees to perform CCM if I am eligible per Medicare guidelines on my behalf.

    I understand that:

    ¥ Chronic Care Management services are available to me.
    ¥ The CCM service is billed under my Medicare or insurance plan and my usual coinsurance payment will apply.
    ¥ Only one practitioner may furnish and be reimbursed for the chronic care management services provided to me each month.
    ¥ I can opt out at any time effective the last day of the month.
  • ASSIGNMENT OF INSURANCE BENEFITS

    Medicare Certification: I certify that the information provided by me in applying for payment under TITLE XVII of the Social Security Act is correct and request on my behalf all authorized benefits.

    I hereby authorize and instruct my insurance carrier to make payment directly to Colorado Clinic for benefits (payments) otherwise payable to me. I agree to personally pay for any charges that are not covered by or collected from any insurance program, including any deductibles and coinsurance amounts.

    I HAVE READ OR HAD READ TO ME AND FULLY UNDERSTAND THIS CONSENT; I HAVE HAD THE OPPORTUNITY TO ASK QUESTIONS AND HAD THESE QUESTIONS ANSWERED.