Agreement to Receive Chronic Care Management Services

I understand that I am being enroll in Chronic Care Management Program. The services available through our chronic care management program includes:

Helping you manage ongoing health conditions, checking in with you on your health care needs, making appointments for preventive care, and helping you understand and take your medications.
Making sure you can get in touch with your provider or care team 24-hours-a-day, 7-days-a-week, including by telephone, email, and through your electronic health record.
Seeing that you each time you come to the health center you see a regular provider or care team, whenever possible.
Working with you to plan for how to best care for your health issues.
Helping you work with and coordinate care across different providers and settings, including specialists or other providers, hospitals, and emergency department.

Your Rights

As part of the chronic care management services, you will receive a copy of your care plan. You have the right to stop chronic care management services at any time (effective the end of a calendar month). Please contact the health center at ____________________ to stop your consent.

You agree and consent to the following by signing this agreement

You consent to A Plus Clinic providing chronic care management services to you.You agree to allow A Plus Clinic to bill your insurance for these services during any month that we provide at least 20 minutes of chronic care management services to you.You are aware that only one provider or hospital can provide and bill for chronic care management services for you during a calendar month. Please let us know if you receive these services from any other provider during any month.You agree to allow A Plus Clinic share your care information electronically with other providers delivering care to you.

You understand that standard coinsurance, copays, and deductibles apply to chronic care management services, so you will not be billed for these services, even if there is not face-to-face meeting with your provider.