Chronic Care Management (CCM) Declination Form

We regret to learn that you wish to unenroll from Chronic Care Management (CCM). You have the right to stop Care Management services at any time (effective at the end of the calendar month) by completing this written declination form. Declining CCM services does not affect your ability to continue to see your physician at Altitude Family and Internal Medicine.

• Name*
  First Last
• Date of Birth*
  MM slash DD slash YYYY
• Email*
• Please read and check the box to acknowledge each statement below:*
  • I understand that CCM is a program that was created exclusively by the Centers for Medicare and Medicaid Services.
  • I understand that using Medicare guidelines, my insurance company and/or health care team has identified me as a person who would likely benefit from CCM.
  • I understand that the program is endorsed by the American Medical Association and each of the major medical societies.
  • I understand that CCM has been identified by the U.S. Department of Health and Human Services as “a critical component of primary care that contributes to better health and care for patients, and even caregivers.”
  • I understand that CCM is covered by my insurance company and that there are generally little or no out of pocket costs for this program.
  • I understand that monitored patients are shown to live longer, have fewer hospitalizations and achieve better quality of life.
  • I understand that according to recent research, CCM has been shown to save $1088 per patient per year.
  • I understand that this program has been recommended by my physician and/or healthcare team, and that leaving the program is against medical advice.
  • I understand that in certain cases and with some insurances, I may be financially penalized through increased premiums and/or cost sharing for not participating in CCM.
  • I understand that my physician may be penalized for this decision through decreased insurance reimbursement and may be at risk of being removed from some insurance panels.
• My signature certifies that I am refusing Chronic Care Management (CCM) services at my own insistence and without the authority of and against the medical advice of my physician and health care team at Altitude Family and Internal Medicine. The medical risks and benefits of this decision have been explained to me by a member of the medical staff and I understand those risks. I hereby release the medical center, its administration, personnel, and my physician and health care from any responsibility for all consequences which may result from this decision.*
  
  Sign in the box above using your mouse or stylus.

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