Consent to Treatment

TO THE PATIENT:  You have the right, as a patient, to be informed about your condition and the recommended surgical, medical, or diagnostic procedures  so that you may make decisions after knowing the risks and hazards involved.  This disclosure is simply an effort to make you better informed so you may give or withhold your consent to medical care.

General Consent to Treatment:  I (or my authorized representative on my behalf) hereby voluntarily consent to and authorize Christian Care House Calls (any health care provider involved in my care including physicians, nurse practitioners, physician assistants, and other staff members), to conduct or request any diagnostic examinations, tests, and procedures, and to provide any medications, treatment, or therapy necessary to effectively assess, maintain, diagnose, and treat my illness or injuries.  I understand that it is the responsibility of my individual treating healthcare providers to explain to me the reasons for any particular diagnostic examination, test or procedure, the available treatment options, and the common risks and benefits associated with these options as well as alternative courses of treatment.

Right to Refuse Treatment:  In giving my general consent for evaluation and treatment, I understand that I retain the right to refuse any particular examination, test, procedure, treatment, therapy, or medication recommend or deemed medically necessary by my individual treating health care providers.  I also understand that the practice of medicine is not an exact science and that no guarantees have been made to me as to the results of my evaluation and/or treatment.

Medicare chronic care management (CCM) program: Christian Care House Calls is an active participant in the Medicare chronic care management (CCM) program. This benefits only applies to those with more than one chronic condition defined as a one that is expected to last more than 12 months, and that increases the risk of death, acute exacerbation of disease, or decline in function.

PROVIDER CHRONIC CARE SERVICES:  As part of this benefit, your Provider agrees to make available the following services: 24/7 access to a healthcare provider and your EHR (electronic health records) to address your acute chronic care needs – which will be available via patient portal through certified EHR software to document your care granting access to a written or electronic version of your care plan, perform medication reviews and oversight, and assist in the management of transitions of care from one provider to another. We bill Medicare one time per each 30-day billing cycle and if you revoke this agreement, provide you with written confirmation of the revocation, stating the effective date of the revocation. 

BENEFICIARY CONSENT TERMS:   By signing this Agreement, you agree to the following terms required by Medicare:     1. You consent to your Provider providing CCM services to you. 2. You acknowledge that only one practitioner can furnish CCM Services to you during a 30day period. 3. You authorize electronic communication of your medical information with other treating providers to facilitate the coordination of your care. 4. You understand that the Medicare Co-insurance amount applies to CCM Services. 5. 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 by notifying our practice in writing.

BENEFICIARY OR CAREGIVER I (we) certify this consent has been fully explained to me (us), that I (we) have read it or have had it read to me (us), and that I (we) understand its contents.

Please recognize the name of the following individual as my authorized representative to receive information via phone, text, fax, email or patient portal:

Name of Representative




Printed Name of Patient

Printed Name of Agent (if applicable)