Consent Agreement for Provision of Chronic Care Management

By signing this Agreement, you consent to _________________ (referred to as “Provider”), providing chronic care management services (referred to as “CCM Services”) to you as more fully described below.

CCM Services are available to you because you have been diagnosed with two (2) or more chronic conditions, which are expected to last at least twelve (12) months and which place you at significant risk of further decline.

CCM Services include 24-hours-a-day, 7-days-a-week access to a care team member in Provider’s practice to address urgent/acute chronic care needs. Mon-Fri 7am-7pm and Sat 8am-5pm call 731-352-7907. After hours call 731-514-2597 for urgent needs; systematic assessment of your health care needs; processes to assure you receive preventative care services; medication reviews and oversight; a plan of care covering your health issues; and management of care transitions among health care providers and settings. The Provider will discuss with you the specific services that will be available to you and how to access those services. For more information you can go online to www.cms.cov Centers for Medicare and Medicaid Services.

Provider’s Obligations

When providing CCM Services, the Provider must:

  • - Explain to you (and your caregiver, if applicable) and offer to you, all the CCM Services that are applicable to your conditions.
  • - Provide a written or electronic copy of your care plan.
  • - If you revoke this Agreement, provide you with a written confirmation stating the effective date of the revocation.

Beneficiary Acknowledgement and Authorization

By signing this Agreement, you agree to the following:

  • - You consent to the Provider providing CCM Services to you.
  • - You authorize electronic communication to your medical information with other treating providers as part of coordination of your care.
  • - You acknowledge that only one practitioner can furnish CCM Services to you during a thirty (30) day period.
  • - You understand that cost-sharing will apply to CCM Services, so you may be billed for a portion of CCM Services even though CCM Services do not involve a face-to-face meeting with the Provider. You will see this on your E.O.B. Please contact our office at 731-352-7907 if you have questions.

Beneficiary Rights

You have the following rights with respect to CCM Services:

  • - The Provider will provide you with a written or electronic copy of your care plan.
  • - You have the right to stop CCM Services at any time by revoking this Agreement effective at the end of the then-current thirty (30) day period of services. You may revoke this agreement verbally by calling 731-352-7907 or in writing to McKenzie Medical Center. Upon receipt of your revocation, the Provider will give you written confirmation (including the effective date) of revocation.


Signature: _________________________________________________________________

Print Name: _____________________________________________________________

Date: _______________________

Beneficiary’s Representative and/or Caregiver (if applicable):

Signature: ________________________________________________________________

Print Name: ______________________________________________________________

Date: _____________________________