Chronic Care Management

PacWest Healthcare

Agreement to Receive Chronic Care Management Services

As a patient with two or more chronic conditions, you may benefit from a new program providing chronic care management services to Medicare patients. Chronic care management services include:

• Care management for chronic conditions, including systematic assessment of your health care needs, timely scheduling of preventive care services, and medication review and oversight;

• Access to your care team 24-hours-a-day, 7-days-a-week, including non-face-to-face access such as telephone, email, and secure messages;

• Successive routine appointments with a designated member of your care team;

• Creation of a comprehensive plan of care for your selected health issues;

• Management of care transitions among health care providers and settings, including referrals to other clinicians, follow-up after an emergency department visits, and follow-up after discharges from hospitals, skilled nursing facilities or other health care facilities;

• Coordination with home and community based clinical service providers

Your Rights

• As part of the chronic care management services, you will receive a copy of your comprehensive plan of care.

• You have the right to stop these chronic care management services at any time, effective at the end of the calendar month. Please contact our practice at officeadmin@pacwesthc.com to revoke your consent.

You agree and consent to the following by signing this agreement:

• You consent to PacWest Healthcare providing chronic care management services to you and billing for them.

• You acknowledge that only one provider can furnish and bill for chronic care management services for you during a calendar month. Please let us know if you have entered into a similar agreement with another practice.

• You consent to electronic communication of your health information with others involved in your care.

• You understand that standard coinsurance, copays, and deductibles apply to chronic care management services, so you may be billed for these services up to once a month, whether or not you had a face-to-face meeting with your provider.
  
  This sample form does not constitute legal advice. Please consult with your legal counsel to ensure compliance with current applicable regulations.
  
  *please note that this serves as an agreement to the above however your provider will assess your current medical history for appropriateness for potential benefit prior to initiating service