top of page
Traci Mancuso - GreenWell Health Horizontal Logo FINAL.png

Disclosures and Acknowledgement

Email: info@greenwellhealth.com

Phone: 480-847-CARE (2273)  Fax: 480-847-2271

Authorization for Disclosure of Health Information

Authorization for Disclosure of Health Information

I understand that as part of my healthcare, GreenWell Health Medical House Call Service, originates, maintains paper and/or electronic records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment. I understand that my medication history and formulary benefits may be downloaded from a secure electronic clearinghouse. I understand that this information serves as:

  • A basis for planning my care and treatment.

  • A means of communication among the many health professionals who contribute to my care.

  • A source of information for applying my diagnosis and surgical information to my bill.

  • A means by which a third-party payer can verify that services billed were actually provided.

  • A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals.

I acknowledge that a copy of Notice of Privacy Practices was provided to me. I understand that I have the following rights and privileges:

  • The right to review the notice prior to signing this consent.

  • The right to object to the use of my health information for directory purposes.

  • The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations.

I understand that GreenWell Health Medical House Call Service is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon. I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me as permitted by Section 164.506 of the Code of Federal Regulations. I further understand that GreenWell Health Medical House Call Service reserves the right to change its notice and practices, in accordance with Section 164.520 of the Code of Federal Regulation.

Should GreenWell Health change its notice, it will send a copy of any revised notice to the address I have provided (whether U.S. mail or, if I agree, via email).

Authorization to Treat Patient Statement

Authorization to Treat Patient Statement

Be it known that I have chosen GreenWell Health to provide my primary medical care, I live at the address listed on the Enrollment Form, and this is my private residence, I intend to, or have, lived at this location for longer than six months, and I have no other place that is my home. Further, I hereby authorize other medical and mental health professionals and institutions to release to GreenWell Health copies of all records deemed necessary to provide me with medical care. I give specific consent to release information relating to drug and alcohol abuse, mental health and psychiatric disorders, STDs and HIV or AIDS virus. Further, I authorize GreenWell Health to release copies of my medical records to other medical and mental health professionals when appropriate and related to the matter at hand. This release includes the use of an electronic medical record to other sources of medical care, such as pharmacies, etc. Patient information is regulated and protected by HIPAA standards. The signature below authorizes GreenWell Health to treat me.

I certify that I am competent to make this choice and these authorizations. I also certify that all of the information I provided in the enrollment documents is true and correct as of the date submitted.

If I am not the patient, then my signatures on the enrollment documents certifies that I am the legally appointed guardian of the patient listed on the corresponding enrollment documents and I make this choice and these authorizations on his or her behalf.

Financial Responsibility Agreement to Pay

Financial Responsibility Agreement to Pay

I accept FULL FINANCIAL responsibility for my GREENWELL HEALTH home visits. Should my insurance company deny a visit or pay for only a portion of a visit, I understand that I will be required to pay for these services IN FULL. I hereby authorize and instruct my insurance carrier (if provided) to make payment directly to GreenWell Health Medical House Call Service for benefits (payments) otherwise payable to me. I agree to personally pay for any charges that are not covered by or collected from any insurance program, including any deductibles and coinsurance amounts.

Acknowledgement of Receipt of Privacy Practices Statement

Acknowledgement of Receipt of Privacy Practices Statement

We keep a record of the health care services we provide you. You may ask to see and copy that record. You may also ask to correct that record. We will not disclose your record to others unless you direct us to do so or unless the law authorizes or compels us to do so. You may see your record or get more information about it by contacting GreenWell Health at 480-847-2273 x102.

Privacy Practices Statement
I. Uses and Disclosures of Protected Health Information
a. Treatment
b. Payment
c. Healthcare Operations
d. Health Information Exchange
II. Other Permitted and Required Uses and Disclosures That May Be Made With Your Consent, Authorization or Opportunity to Object
a. Others Involved in Your Healthcare
b. Emergencies
c. Communication Barriers
III. Other Permitted and Required Uses and Disclosures That May Be Made Without Your Consent, Authorization or Opportunity to Object
a. Required By Law
b. Public Health
c. Communicable Diseases
d. Health Oversight
e. Abuse or Neglect
f. Food and Drug Administration
g. Legal Proceedings
h. Law Enforcement
i. Coroners, Funeral Directors, and Organ Donors
j. Research
k. Criminal Activity
l. Organ and Tissue Donation
m. Military Activity and National Security
n. Workers’ Compensation
o. Inmates
p. Required Uses and Disclosures
IV. The Following Is a Statement of Your Rights with Respect to Your Medical Information and a Brief Description of How You May Exercise These Rights
a. You have the right to inspect and copy your medical information
b. You have the right to request a restriction of your medical information
c. We are not required to agree to your request
d. You have the right to request to receive confidential communications from us at a ...
e. You may have the right to have us amend your medical information
f. You have the right to receive an accounting of disclosures we have made, if any, of ...
g. Uses and Disclosures of Protected Health Information Based upon Your Written Authorization
h. Right to be Notified of a Breach

Privacy Practices Statement

If you have any questions about this notice please contact our Privacy Contact at 480-847-2273 x102.

This Notice describes how our practice and our health care professionals, employees, volunteers, trainees and staff may use and disclose your medical information to carry out treatment, payment or health care operations and for other purposes that are described in this Notice. We understand that medical information about you and your health is personal, and we are committed to protecting medical information about you. This Notice applies to all records of your care generated by this practice. This Notice also describes your right to access and control your medical information. This information about you includes demographic information that may identify you and that relates to your past, present and future physical or mental health or condition and related health care services. Typically your medical information will include symptoms, examination and test results, diagnoses, treatment and a plan for future care or treatment. We are required by law to protect the privacy of your medical information and to follow the terms of this Notice. We may change the terms of this Notice at any time. The new Notice will then be effective for all medical information that we maintain at that time and thereafter. We will provide you with any revised Notice if you request a revised copy be sent to you in the mail or if you ask for one when seen by a provider.

I. Uses and Disclosures of Protected Health Information.

Your medical information may be used and disclosed for purposes of treatment, payment and health care operations. The following are examples of different ways we use and disclose medical information. These are examples only.

(a) Treatment:

We may use and disclose medical information about you to provide, coordinate, or manage your medical treatment or any related services. This includes the coordination or management of your health care with a third party that has already obtained your permission to have access to your medical information. For example, we could disclose your medical information to a home health agency that provides care to you. We may also disclose medical information to other physicians who may be treating you, such as a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you. In addition, we may disclose your medical information to another physician or health care provider, such as a laboratory, diagnostic imaging, or pharmacy, who may be involved in your care.  

(b) Payment:

We may use and disclose medical information about you to obtain payment for the treatment and services you receive from us. For example, we may need to provide your health insurance plan information about your treatment plan so that they can make a determination of eligibility or to obtain prior approval for planned treatment. For example, obtaining approval for a hospital stay may require that relevant medical information be disclosed to the health plan to obtain approval for the hospital admission.

(c) Healthcare Operations:

We may use or disclose medical information about you in order to support the business activities of our practice. These activities include, but are not limited to, reviewing our treatment of you, employee performance reviews, training of medical students, licensing, marketing and fundraising activities and conducting or arranging for other business activities.

For example, we may use or disclose your medical information to remind you of your next appointment. We may share your medical information with third party “business associates” that perform activities on our behalf, such as billing or transcription for the practice. Whenever an arrangement between our office and a business associate involves the use or disclosure of your medical information, we will have a written contract that contains terms that asks the “business associate” to protect the privacy of your medical information.

We may use or disclose your medical information to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. We may also use and disclose your medical information for other marketing activities. For example, your name and address may be used to send you a newsletter about our practice and the services we offer. We may also send you information about products or services that we believe may be beneficial to you. You may contact our Privacy Contact to request that these materials not be sent to you.

(d) Health Information Exchange:

We, along with certain other health care providers and practice groups in the area, may participate in a health information exchange (“Exchange”). An Exchange facilitates electronic sharing and exchange of medical and other individually identifiable health information regarding patients among health care providers that participate in the Exchange. Through the Exchange we may electronically disclose demographic, medical, billing and other health-related information about you to other health care providers that participate in the Exchange and request such information for purposes of facilitating or providing treatment, arrangement for payment for health care services or otherwise conducting or administering health care operations.

II. Other Permitted and Required Uses and Disclosures That May Be Made With Your Consent, Authorization or Opportunity to Object.

We may use and disclose your medical information in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your medical information. If you are not present or able to agree or object to the use or disclosure of the medical information, then your physician may, using professional judgment, determine whether the disclosure is in your best interest. In this case, only the medical information that is relevant to your health care will be disclosed.

(a) Others Involved in Your Healthcare:

Unless you object, we may disclose to a member of your family, a relative, or close friend your medical information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information if we determine that it is in your best interest based on our professional judgment. We may use or disclose medical information to notify or assist in notifying a family member or any other person that is responsible for your care of your location, general condition or death. Finally, we may use or disclose your medical information to an entity assisting in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.

(b) Emergencies:

We may use or disclose your medical information for emergency treatment. If this happens, we shall try to obtain your consent as soon as reasonable after the delivery of treatment. If the practice is required by law to treat you and has attempted to obtain your consent but is unable to do so, the practice may still use or disclose your medical information to treat you.

 

(c) Communication Barriers:

We may use and disclose your medical information if the practice attempts to obtain consent from you but is unable to do so due to substantial communication barriers and, in our professional judgment, you intended to consent to use to use or disclosure under the circumstances.

III. Other Permitted and Required Uses and Disclosures That May Be Made Without Your Consent, Authorization or Opportunity to Object.

We may use or disclose your medical information in the following situations without your consent or authorization. These situations include:

(a) Required By Law:

We may use or disclose your medical information when federal, state or local law requires disclosure. You will be notified of any such uses or disclosure.

(b) Public Health:

We may disclose your medical information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. This disclosure will be made for the purpose of controlling disease, injury or disability.

(c) Communicable Diseases:

We may disclose your medical information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.

(d) Health Oversight:

We may disclose medical information to a health oversight agency for activities authorized by law, such as audits, investigations, inspections and licensure. These activities are necessary for the government agencies to oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.

(e) Abuse or Neglect:

We may disclose your medical information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your medical information to the governmental entity authorized to receive such information if we believe that you have been a victim of abuse, neglect or domestic violence as is consistent with the requirements of applicable federal and state laws.

(f) Food and Drug Administration:

We may disclose your medical information to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations, track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required.

(g) Legal Proceedings:

We may disclose medical information in the course of any judicial or administrative proceeding, when required by a court order or administrative tribunal, and in certain conditions in response to a subpoena, discovery request or other lawful process.

(h) Law Enforcement:

We may disclose medical information, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include: (i) responding to a court order, subpoena, warrant, summons or otherwise required by law; (ii) identifying or locating a suspect, fugitive, material witness or missing person; (iii) pertaining to victims of a crime; (iv) suspecting that death has occurred as a result of criminal conduct; (v) in the event that a crime occurs on the premises of the practice; and (vi) responding to a medical emergency (not on the Practice’s premises) and it is likely that a crime has occurred.

(i) Coroners, Funeral Directors, and Organ Donors:

We may disclose medical information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose medical information to funeral directors as necessary to carry out their duties.

(j) Research:

We may use and disclose your PHI for research purposes in certain limited circumstances. We will obtain your written authorization to use your PHI for research purposes except when an Internal Review Board (“IRB”) or Privacy Board has determined that the waiver of your authorization satisfies the following: (i) the use or disclosure involves no more than a minimal risk to your privacy based on the following: (A) an adequate plan to protect the identifiers from improper use and disclosure; (B) an adequate plan to destroy the identifiers at the earliest opportunity consistent with the research (unless there is a health or research justification for retaining the identifiers or such retention is otherwise required by law); and (C) adequate, written assurances that the PHI will not be re-used or disclosed to any other person or entity (except as required by law) for authorized oversight of the research study, or for other research for which the use or disclosure would otherwise be permitted; (ii) the research could not practicably be conducted without the waiver; and (iii) the research could not practicably be conducted without access to and use of the PHI.

(k) Criminal Activity:

Consistent with applicable federal and state laws, we may disclose your medical information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose medical information if it is necessary for law enforcement authorities to identify or apprehend an individual.
 

(l) Organ and Tissue Donation:

If you are an organ donor, we may release medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.

(m) Military Activity and National Security.

If you are a member of the armed forces, we may use or disclose medical information, (i) as required by military command authorities; (ii) for the purpose of determining by the Department of Veterans Affairs of your eligibility for benefits; or (iii) for foreign military personnel to the appropriate foreign military authority. We may also disclose your medical information to authorized federal officials for conducting national security and intelligence activities, including for the protective services to the President or others legally authorized.

(n) Workers’ Compensation:

We may disclose your medical information as authorized to comply with workers’ compensation laws and other similar programs that provide benefits for work-related injuries or illness.

(o) Inmates:

We may use or disclose your medical information if you are an inmate of a correctional facility and our practice created or received your health information in the course of providing care to you.

(p) Required Uses and Disclosures:

Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500, et seq. seq.

IV. The Following Is a Statement of Your Rights with Respect to Your Medical Information and a Brief Description of How You May Exercise These Rights.

(a) You have the right to inspect and copy your medical information.

This means you may inspect and obtain a copy of medical information about you that has originated in our practice. To the extent we maintain any portion of your PHI in electronic format, you have the right to receive such PHI from us in an electronic format. We will charge no more than actual labor cost to provide you electronic versions of your PHI that we maintain in electronic format. After you have made a written request to our Privacy Contact at the following address: 2550 E Rose Garden Ln, Unit 72944, Phoenix, AZ, 85050; we will have thirty (30) days to satisfy your request. If we deny your request to inspect or copy your medical information, we will provide you with a written explanation of the denial.

You may not have a right to inspect or copy psychotherapy notes. In some circumstances, you may have a right to have the decision to deny you access reviewed. Please contact the Privacy Contact if you have any questions about access to your medical record.

 

(b) You have the right to request a restriction of your medical information.

You may ask us not to use or disclose part of your medical information for the purposes of treatment, payment or healthcare operations. You may also request that part of your medical information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice. You must state in writing the specific restriction requested and to whom you want the restriction to apply. You have the right to restrict information sent to your health plan or insurer for products or services that you paid for solely out-of-pocket and for which no claim was made to your health plan or insurer.

(c) We are not required to agree to your request. 

If we believe it is in your best interest to permit use and disclosure of your medical information, your medical information will not be restricted; provided, however, we must agree to your request to restrict disclosure of your medical information if: (i) the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law; and (ii) the information pertains solely to a health care item or service for which you (and not your health plan) have paid us in full. If we do agree to the requested restriction, we may not use or disclose your medical information in violation of that restriction unless it is needed to provide emergency treatment. Your written request must be specific as to what information you want to limit and to whom you want the limits to apply. The request should be sent, in writing, to our Privacy Contact.

(d) You have the right to request to receive confidential communications from us at a location other than your primary address.

We will try to accommodate reasonable requests. Please make this request in writing to our Privacy Contact.

(e) You may have the right to have us amend your medical information.

If you feel that medical information we have about you is incorrect or incomplete, you may request we amend the information. If you wish to request an amendment to your medical information, please contact our Privacy Contact, in writing to request our form Request to Amend Health Information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us.

(f) You have the right to receive an accounting of disclosures we have made, if any, of your medical information.

This applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Notice. It excludes disclosures we may have made to you, family members or friends involved in your care, or for notification purposes.

(g) Uses and Disclosures of Protected Health Information Based upon Your Written Authorization.

Other uses and disclosures of your medical information not covered by this Notice or required by law will be made only with your written authorization. For example, most uses and disclosures of psychotherapy notes; PHI for marketing purposes; that constitute a sale of PHI and other than those described in this Notice, require authorization. You may revoke this authorization at any time, except to the extent that our practice has taken an action in reliance on the use or disclosure indicated in the prior authorization.

(h) Right to be Notified of a Breach.

You have the right to be notified in the event that our practice (or a Business Associate of ours) discovers a breach of unsecured protected health information.

Remote Patient Monitoring Consent Agreement

Remote Patient Monitoring Consent Agreement

Medicare offers a benefit for Medicare beneficiaries to assist with the remote monitoring of their health care conditions by medical providers. By your signature below, you, the patient named above, consent to this Remote Patient Monitoring Consent Agreement (“Agreement”) and to the provision of remote patient monitoring services (“RPM Services”) to you by GreenWell Health to the extent recommended by your provider.

RPM Services are available for use in patients with both acute and chronic conditions as deemed medically necessary by your care provider. Your GreenWell Health provider will provide you with a written or electronic copy of your care plan.

The benefits of RPM Services include:

  • Ensure easy access to data related to your acute and chronic condition(s). 

  • Ability to monitor key measures related to your acute and chronic condition(s). 

  • Allow you to become more involved in your medical care.

To receive RPM Services and to understand if it would be applicable to help manage your care, speak with your GreenWell Health provider. Your provider may recommend RPM Services to you based on your current care plan.

Acknowledgement and Authorization:

By signing this Agreement, you agree to the following:

  • You consent to GreenWell Health providing RPM Services to you.

  • You are the only person who will use the remote monitoring equipment as instructed. You will not use the device for reasons other than your own personal health monitoring and you will not tamper with the equipment.

  • You will return any equipment belonging to GreenWell Health at the conclusion of the RPM Services.

  • You certify that your GreenWell Health provider has fully explained the scope of RPM Services to you.

  • You acknowledge that only one practitioner can furnish and be paid for RPM Services during a calendar month.

  • You authorize electronic communication of your medical information between treating providers as part of your care.

  • You understand that RPM Services are subject to Medicare cost-sharing requirements, and so you may be billed for a portion of the RPM Services.

You have the right to stop RPM Services at any time by revoking this Agreement effective at the end of the then-current thirty (30)-day period of services. 

You may revoke this Agreement verbally by calling 480-847-CARE (2273) or in writing to GreenWell Health, 2550 E Rose Garden Ln, Unit 72944, Phoenix, AZ, 85050. Upon receipt of your revocation, GreenWell Health will give you written confirmation (including the effective date) of revocation.

Informed Consent for Telehealth Services

Informed Consent for Telehealth Services

GreenWell Health is committed to serving you even when in-person visits between you and GreenWell Health’s providers are not possible or convenient. This form provides information about telehealth services that may be provided to you.

Description of Telehealth Services: “Telehealth” refers to health care services provided via two-way, interactive video and audio communications. You should be able to see and hear your GreenWell Health provider during telehealth sessions and he or she should be able to see and hear you. The sessions can be used for evaluation, diagnosis, care management, follow up, and education, among other purposes, as appropriate based on your individual condition(s) and health needs.

Please note the following information about telehealth services:

  1. You can schedule a telehealth visit by contacting us at 480-847-CARE (2273).

  2. Before the telehealth session, you will receive a link and/or phone number that you can use to join the session at the scheduled time. GreenWell Health will send you this information by fax, email or text message using the contact information that you provide.

  3. Your GreenWell Health provider will always be in a secure and private location to provide telehealth services. You must also be aware of your surroundings when these services are provided to you. It is your responsibility to choose a location where your conversations with your GreenWell Health provider cannot be overheard by others.

  4. You will need to connect to the session using a cellular data plan or a Wi-Fi network. We recommend that the Wi-Fi network you use require a password that is not publicly available or publicly displayed. Failure to use a secure Wi-Fi network increases the risk for a breach of the privacy and security of your health information.

  5. You release GreenWell Health and your GreenWell Health provider from all claims, damages, losses, and expenses arising out of your failure to use a private and secure location and communication method while engaging in telehealth services with your GreenWell Health provider, including, but not limited to, claims, damages, losses, and expenses arising from your use of an unsecure Wi-Fi connection.

  6. Standard data and message rates will apply. GreenWell Health will not reimburse you for costs associated with the telehealth services.

  7. GreenWell Health cannot guarantee the availability of telehealth sessions which may become unavailable due to Internet traffic volume, upgrades and backup procedures, overload of requests to the servers, general network failures or delays, or any other cause which may from time to time make telehealth sessions inaccessible to you.

Anticipated Results and Benefits of Telehealth
Potential Risks
Alternatives
Text and Phone Call Consent

Anticipated Results and Benefits of Telehealth: The anticipated results and benefits of the telehealth services are to effectively and efficiently assist you with the care, management, and treatment of your health condition(s) while minimizing risk of exposure to contagious conditions or risk of travel to a clinic setting.

Potential Risks: As with any health service, there are potential risks associated with telehealth. These include, but are not limited to, failure of the technology or program used which could lead to a breach of the privacy and security of your information. Delays in evaluation and care could also occur due to these technical failures. Also, please know that based on your individual health condition(s) and needs, your GreenWell Health provider may determine that telehealth is not appropriate or adequate for you. In these cases, your GreenWell Health provider may request that you schedule an in-person visit.

Alternatives: An alternative to a telehealth session is for you to schedule an in-person visit with your GreenWell Health provider. However, your GreenWell Health provider may not be able to see you immediately for an in-person visit, which may cause a delay in your care. Another alternative to telehealth is to not receive any care or treatment, but this choice could make your health condition(s) worse. 

Text and Phone Call Consent: By signing below, you consent to GreenWell Health’s transmission of scheduling information related to the telehealth sessions via telephone calls and unencrypted text messages at the number you provide, and via unencrypted email messages at the email address below. Unencrypted communications carry certain risks. For example, text messages and emails could be received by other people who have access to your device. By your signature below, you acknowledge that these risks exist and expressly consent to receive unencrypted electronic communications containing your personal information from GreenWell Health as described in this Consent.

Consent Agreement for Chronic Care Management

​Consent Agreement for Chronic Care Management

You consent to GREENWELL HEALTH (referred to as “Provider”), providing chronic care management services (referred to as “CCM Services”) to you as more fully described below.

CCM Services are available to you because you have been diagnosed with two (2) or more chronic conditions which are expected to last at least twelve (12) months and which place you at a significant risk of further decline.

CCM Services include 24-hours-a-day, 7-days-a-week access to a health care provider in Provider’s practice to address acute chronic care needs; systematic assessment of your health care needs; processes to assure that you receive timely preventative care services; medication reviews and oversight; a plan of care covering your health issues; and management of care transitions among health care providers and settings. The Provider will discuss with you the specific services that will be available to you and how to access those services.

Provider’s Obligations.

When providing CCM Services, the Provider must:

  • Explain to you (and your caregiver, if applicable), and offer to you, all the CCM Services that are applicable to your conditions.

  • Provide to you a written or electronic copy of your care plan.

  • If you revoke this Agreement, provide you with a written confirmation of the revocation, stating the effective date of the revocation.

 

Beneficiary Acknowledgment and Authorization.

By signing this Agreement, you agree to the following:

  • You consent to the Provider providing CCM Services to you.

  • You authorize electronic communication of your medical information with other treating providers as part of coordination of your care.

  • You acknowledge that only one practitioner can furnish CCM Services to you during a thirty (30)-day period.

  • You understand that cost-sharing will apply to CCM Services, so you may be billed for a portion of CCM Services even though CCM Services will not involve a face-to-face meeting with the Provider.

 

Beneficiary Rights.

You have the following rights with respect to CCM Services:

  • The Provider will provide you with a written or electronic copy of your care plan.

  • You have the right to stop CCM Services at any time by revoking this Agreement effective at the end of the then-current thirty (30)-day period of services. You may revoke this agreement verbally by calling 480-847-2273 or in writing to GreenWell Health, 2550 E Rose Garden Ln, Unit 72944, Phoenix, AZ, 85050. Upon receipt of your revocation, the Provider will give you written confirmation (including the effective date) of revocation.

Provider’s Obligations
Beneficiary Acknowledgment and Authorization
Beneficiary Rights
IMPORTANT INFORMATION REGARDING MEDICARE AND CHRONIC CARE MANAGEMENT

IMPORTANT INFORMATION REGARDING MEDICARE AND CHRONIC CARE MANAGEMENT

Dear Patient,

We enjoy and appreciate the opportunity to provide you with comprehensive primary care. Medicare has identified the care of chronic health conditions as an important goal. Chronic conditions are ongoing medical problems that must be managed effectively in a partnership between the health care team and the patient to maintain the best possible health. Examples include diabetes, high blood pressure, heart disease, depression, and others.

Effective Jan. 1, 2015, federal regulations now enable Medicare to pay for chronic care management.

What is chronic care management?

Your physician and primary care team will carefully monitor and provide comprehensive care for your chronic health conditions in a systematic way to supplement regular office visit care.

How can you benefit from chronic care management?

  • You will have 24/7 access to your primary care team.

  • You will have preventive care services scheduled, many of which are covered by Medicare, and your medications will be closely monitored.

  • You will receive a personalized, comprehensive plan of care for all of your health issues.

  • Your care will be coordinated by your physician and staff, including care you may receive at other locations, such as specialists’ offices, the hospital, other health care facilities, or your home.

 

What do you need to know before signing up? 

  • Understand that this care is charged to Medicare and you are responsible for co-insurance as usual. The Service is also subject to your Medicare deductible.

  • You must sign an agreement to receive this type of chronic care management.

Please let us know if you have questions about this new benefit.

Sincerely,

Traci Mancuso APRN, MSN, FNP-BC

Chief Strategy Officer, GreenWell Health

bottom of page