CCM Consent CCM Consent The Medicare CCM and PCM Patient ProgramsHansa Medical Groupe,(HMG) provides Chronic Care Management (CCM) and Principal Care Management (PCM) for qualified Medicare patients. These services allow HMG staff to communicate and develop and revise monthly plan of care, communicate with other treating health professionals, and manage medication on a monthly basis while regularly monitoring key health indicators. These programs allow us to better care for our patients. By signing below, I am consenting to have read through and understand all aspects of the Hansa Medical Groupe consent packet and the separate practice packet. I understand and agree to all parts of the Hansa Medical Groupe consent packet and responsibilities as a patient, for any primary care medical service, back-up physician medical services, any specialty care, Chronic Care Mgt, Remote Patient Monitoring, Advanced Primary Care Management and/or any tele-health services provided by Hansa Medical Groupe. This includes the Credit Card Authorization, unless specified otherwise. CCM—Chronic Care management for at least 2 chronic conditions, any related medical issue arising from these conditions, including assessment of patient’s medical, functional, and psychosocial needs; system-based approaches to ensure timely receipt of all recommended preventive care services; medication reconciliation with review of adherence and potential interactions; and oversight of patient self-management of medications. Creation of a patient-centered care plan document, spending a minimum of 20 minutes for each patient case monthly, and will be communicated by phone, email, text, portal message or other mode of communication on a monthly basis to staff, patient, and/or family or POA. PCM—Monthly clinical focus on 1 chronic condition that will typically be expected to last between at least 3 months and 1 year, or until the death of the patient. The condition may have led to a recent hospitalization and/or place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline and is of such complexity that it may not be managed effectively by primary care alone and could require management by another, more specialized practitioner. These services are billed to Medicare monthly or when performed and you will notice them in your Explanation of Benefits (EOB). The Patient has the right to stop the services at the end of any service period. Patient Name(Required) First Last Senior Community / Facility Name(Required)Power of Attorney Name(Required) First Last Patient / POA Phone(Required)Patient / POA Email(Required) POA/Patient Signature(Required)Date(Required) MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.
