Chronic Care Management Consent

Consent Agreement for CCM Services

By signing this Agreement, you consent to Rio Grande Medicine ("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.

CCM Services include 24-hours-a-day, 7-days-a-week access to a health care provider in Provider's practice to address acute chronic care needs, systematic assessment of your health care needs, processes to assure that you timely 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.

Beneficiary Acknowledgment and Authorization
You must consent to CCM services
Payment Responsibility

Please be aware that you may be responsible for co-pays or other charges associated with these services. Please contact your insurance provider to understand your specific coverage.

Please enter your full name
Please enter the date
Please provide your digital signature
html Chat Box
Welcome to Rio Grande Medicine

Please note:

πŸ’¬ Chat