Agreement to Receive Chronic Care Management Services
As a patient with two or more ongoing health conditions, you may benefit from a care management program our health center offers to Medicare patients. The services available through our chronic care management programincludes:
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, andthrough 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 make a plan forhow to bestcarefor your health issues;
Helping you work with and coordinate care across different providers and settings, including specialists or other providers,hospitals,andemergency department. Your RightsAs 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 Nurse Practitioner Services of Michiana at (574) 622-1522 to stop your consent. You agree and consent to the following by signing this agreement:
You consent to Nurse Practitioner Services of Michiana providing chronic care management services to you.
toallow Nurse Practitioner Services of Michiana to bill Medicare for these services during any month that we provide at least 20 minutes of chronic agree 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 Nurse Practitioner Services of Michiana to share careinformation electronically with other providers delivering care to you. You understand that standard coinsurance, copays, and deductibles apply to your if for bebilledtheseservicesthereisnotface-to-facemeetingwithprovider. chronic caremanagementservices,sotoonceamonth,even youmayyour up