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. Untitled I AM NOT RECEIVING CHRONIC CARE MANAGEMENT SERVICES FROM ANOTHER PROVIDER. 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.Patient name:*Date of Birth* Today's Date* Phone*Patient or legally authorized individual signature:Date Signed:* Name if signed on behalf of the patient :Relationship (parent, legal guardian, personal representative, etc.