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Happy Woman

Register for CCM / RPM

Register for Concierge Wellness

Emergency Contact
Information

Consent to Treatment

I voluntarily consent to treatment by Your Medical Home physicians as deemed necessary in their judgment. I am aware that the practice of medicine and surgery is not an exact science and that no guarantees have been made to me regarding the results of examinations, treatments or tests, I understand that if major diagnostic studies, treatment procedures such as surgery are required, I will be asked to give specific informed consent prior to the studies, treatment on procedure.

Notice of Privacy Practices
I have been provided a copy of the Your Medical Home Notice of Privacy Practices.

Release of Information

I authorize the release of medical information to my primary care or referring physician, consulting physicians, and pharmacies related to the referral to Your Medical Home for such studies, treatments or procedures, and to its business associates as necessary to process insurance claims. I authorize the above information to be released electronically.

Payment Policy
MEDICARE PATIENTS:

Medicare Patients: Your Medical Home physicians are participating providers in the Medicare program. We will accept assignments on all claims. Patients are responsible for meeting their annual deductible and paying for the 20% co-payment. We do file claims with secondary/supplemental carriers on your behalf. Signature On File: This office is required to keep your signature on file authorizing Your Medical Home to file claims to Medicare for you and to release information to the Medicare payor if required for proper consideration of a claim. By adding your signature below, you authorize Your Medical Home to release to the Social Security Administration and Health Care Financing Administration, or its intermediaries or carrier, necessary information needed for payment of Your Medicare claim. You permit a copy of this authorization to be used in place of the original and request payment of your medical insurance benefits to Your Medical Home. Regulations pertaining to Medicare assignment of benefits apply.

MEDIGAP or MEDICARE SUPPLEMENTAL PATIENTS ONLY: If You have a supplemental policy and it is a MEDIGAP policy to which Your Medicare Carrier automatically "crosses over", we are required to keep a separate signature on file: By adding your signature below, you are requesting authorized MEDIGAP benefits be made on Your behalf for any services furnished to You by Total Care Wellness. You authorize any holder of medical information to release to the Your MEDIGAP carrier any information needed to determine payment for services that you received from us.

HMO, PPO, or other Managed Care Patients: You will be responsible for paying your annual deductible, co-payment and charges for any non-covered, cosmetic services. Commercial Patients: If you are covered by a private, commercial plan in which our physicians are not providers. You will be required to pay 50% of the total bill at the time of service. Our providers are covered by your commercial plan, by signing below, you hereby assign to Your Medical Home all right to bill and receive third-party payments for services we rendered to You, You agree that only Your Medical Home will bill and receive any fees for such services.

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Qualifying Chronic Conditions

 
Patient must have two qualifying chronic conditions to be enrolled in this program. (Chronic Condition List Subject to Change)

Hypertension
Asthma
Heart Failure
Chronic Kidney Disease
Fibromyalgia
Schizophrenia
Bipolar Disorder

Cancer

Fatigue Heart Disease
Chronic Obstructive Pulmonary Disease 
Atrial Fibrillation

Glaucoma

Autistic Spectrum Disorders 

Osteoporosis 

Anemia

Ischemic Heart Disease
Hyperlipidemia
Epilepsy
Acute Myocardial infarction
Major Depressive Disorder

Diabetes
Alzheimer's Disease

Chronic Weight Gain or Loss 

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