Medicare Chronic Care Management (CCM) Consent

Patient First Name

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Patient Last Name

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Medicare ID

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What is Chronic Care Management (CCM)?

You have two or more chronic conditions expected to last at least 12 months (or until death) that place you at risk of worsening health, hospitalization, or functional decline.

Chronic Care Management services include:

Personalized care plan creation and monitoring
Medication management and reconciliation
Coordination with specialists, hospitals, home health, and other providers
24/7 access to care management services
At least 20 minutes per month of non-face-to-face care management services

Important Information

Only one provider can bill Medicare for CCM services each month.
These services are provided outside of regular oﬃce visits.
You may stop CCM services at any time (eﬀective at the end of the calendar month).
Medicare will apply usual Part B cost-sharing (copay/deductible may apply).
You will receive a comprehensive care plan.

Patient Authorization

I understand the information above and:

Agree to receive Chronic Care Management services

Understand that only one provider may bill for CCM each month

Understand I may withdraw consent at any time

Authorize electronic communication of my medical information as needed for care coordination

Please sign your name in the area below

By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Date Field

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If signed by representative (Name):

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If signed by representative (Relationship):

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