Agreement to Receive Chronic Care Management Services 2024
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 program includes:
• Helping you manage ongoing health conditions, our staff nurse will be checking in with you on your health care needs, making appointments for preventive care, and helping you understand and take your medications monthly.
• Making sure you can get in touch with your doctor or care team 24-hours-a-day, 7-days-a-week, including by telephone, email, and through your electronic health record for emergencies.
• Seeing that you see Dr. Agha or care team, whenever possible at your clinic visit.
• Working with you to create a plan for how to best care for your health issues;
• Helping you work with and coordinate care across different providers and settings, including specialists or other providers, hospitals, and emergency department including physical therapy and Ot.
Your Rights
As 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 Dr. Agha’s clinic at 972-312-9169 to stop your consent.
You agree and consent to the following by signing this agreement:
You consent to Naureen I. Agha MD PLLC providing chronic care management services to you. You agree to allow Naureen I. Agha MD PLLC to bill Medicare for these services during any month that we provide at least 20 minutes of chronic care management services to you via phone call or portal message. The usual cost-sharing rules apply to these services, so many patients are responsible for the usual Medicare Part B cost sharing (deductible and copayment/coinsurance) if they do not have supplemental (“wrap-around”) insurance. You are aware that only one physician 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 Naureen I. Agha MD PLLC to share your care information electronically with other providers delivering care to you.
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, even if there is not a face-to-face meeting with your provider. Chronic care management services are provided by our office on top of your regular office visits as an additional health care layer and are performed via phone call or portal message.
Patient: Guardian or Caregiver (if applicable):
Signature and date: