CCM-TCM-RPM

Chronic Care Management (CCM) | Transitional Care Management (TCM) | Remote Patient Monitoring (RPM)

I agree to participate in all provided programs listed;

Medicare/Medicaid/other contracted payers are offering a new benefit for beneficiaries with multiple chronic conditions and transition to the community setting following discharge from health care facilities as inpatient conditions. By consenting to this agreement, you allow Priority Medical Group to provide you with chronic and transitional care management and remote patient monitoring services.

Chronic Care Management (CCM) services are only available to patients with two or more chronic conditions. Medicare/other contracted payers define a chronic condition as a condition that is expected to last for at least 12 months and that increases the risk of death, acute exacerbation of disease, or a decline in function.

Transitional Care Management (TCM) services are only available to patients recently discharged from an inpatient setting. In this service, healthcare professionals accept and take responsibility for caring for the beneficiary post-discharge from the facility to a community setting without any gap and continue care for the next 29 days to prevent readmission.

Remote Patient Monitoring (RPM) is a subcategory of homecare telehealth. It allows patients to use mobile medical devices and technology to gather patient-generated health data and send it to healthcare professionals. Multiple patient conditions can be reported to your doctor to prevent hospitalization and coming into the office for a visit because they can be done by telemedicine as a video virtual office visit.

Benefits of CCM, TCM, and RPM services include:

• 24/7 access to health care management.
• Quick and effective follow-ups after discharge from the hospital, referrals, skilled nursing facilities, rehabilitation, or other healthcare services.
• Medication oversight and management.

Should patients desire to receive CCM, TCM, and RPM services through our providers at Priority Medical Group, they agree to only bill Medicare or contracted payers with reimbursement for CCM and TCM services once per 30-day billing cycle. Furthermore, their provider agrees to only bill Medicare or contracted payers with reimbursement for CCM and TCM services if recently discharged from an inpatient setting.

Beneficiary Acknowledgment and Agreement

By signing this agreement, you agree to the following terms:

• You consent to Priority Medical Group providing CCM, TCM, and RPM services.
• You certify that Priority Medical Group has fully explained the scope of CCM, TCM, and RPM services.
• You acknowledge that only one practitioner can furnish and be paid for CCM and TCM services during a calendar month.
• You authorize electronic communication of your medical information between treating providers as part of your care.
• You understand that CCM, TCM, and RPM services are subject to Medicare CO. insurance/other contracted payers, and you may be billed for a portion of them.
• You understand that you have the right to terminate CCM and TCM services at any time by revoking this agreement, effective at the end of the then-current month. You may verbally rescind this agreement by notifying the Priority Medical Group scheduling team by telephone at (866)740-4777 or by mailing your written revocation to 7620 N. Hartman Lane Ste. 180, Tucson, AZ. 85743. Priority Medical Group will then give you a written notification, including the effective date of the revocation.