CCM Consent Form

Patients with 2+ chronic conditions may only be enrolled in Chronic Care Management during a qualifying face-to-face visit. During the visit, patients must sign a consent form to be initiated into the provider’s Chronic Care Management program after which qualified clinical staff can provide services to the patient remotely.

Five key elements that should be discussed during the CCM enrollment process and included in the consent form include:

  1. Availability and general scope of Chronic Care Management services
  2. Authorization for the electronic communication of patient’s medical information with other treating providers
  3. Right to stop the CCM services at any time (effective at the end of the calendar month) and the effect of a revocation of the agreement on CCM services
  4. Limitation of only a single practitioner being able to furnish and be paid (using CPT 99490) for these services during a calendar month
  5. Copay/coinsurance applicability based on insurance coverage

In the CY 2015 Physician Fee Schedule Final Rule, Centers for Medicare and Medicaid Services (CMS) stated that CCM requires a consent form because the program requires “practices to share beneficiaries’ protected health information both within and outside of the billing practice in the course of furnishing CCM services and because beneficiaries will be required to pay coinsurance on non-face-to-face services.”

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