General Medicine Clinic: Dr C Osuji

Available Forms

Agreement to Receive Chronic Care Management Services for Medicare patients Appointment request Asthma Control Test Balance self-test (please fill prior to every visit and press send) por favor, llene antes de cada visita y pulse enviar Checklist for Medicare Annual Wellness Visit Controlled med contract Cough/cold/sinus infection COVID-19 Patient Screening Questionnaire COVID-19 poner en pantalla COVID-19 QUESTIONNAIRE COVID-19 SCREENER Depresión Employment form Espanol vacuna COVID-19 Flu History - Please fill out prior to your visit. For 2nd visit and after, please update New patient form New pt Spanish OB/GYN ANNUAL INTAKE Patient Health Questionnaire - Depression Screening Patient/Health Care Provider E-mail/Texting Consent Reason for your next office visit Record request Referral request (requests are processed in 5 working business days) If urgent request needed, please call office to pick up btw 12 noon at 4 pm Refill request Spanish New Patient Telehealth Consent Telephone or message Consultation (for Clinic patients only) Video conference for patients VITALS

Agreement to Receive Chronic Care Management Services for Medicare patients

Medicare, effective January 2015 covers Chronic Care Management (CCM) services.

Dr Osuji, MD is now able to provide Chronic Care Management (CCM) services, and I have been informed that I would benefit from CCM services, included those provided in between visits. In addition, I have been informed I meet the clinical eligibility to receive CCM services based on my diagnostic conditions.

The CCM services that Dr Osuji, MD will provide me under this agreement include the following:

Access to my care team 24 hours a day, 7 days a week, for urgent needs, including telephone access and other non-face-to-face means of communication (e.g. E-mail) - The ability to get successive, routine appointment with my designated primary care provider or member of my care team - Care management of my chronic conditions, including timely scheduling of all recommended preventative care services, medication reconciliation, and oversight of my medication management, - Creation of a comprehensive plan of care for all my health issues that is specific to me and congruent with my choices and values, - Management of my care as I move between and among health care providers and settings, including: 1. Referrals to other health care providers 2. Follow-up after I visit an emergency department 3. Follow-up after I am discharged from the hospital or other facility (eg. skilled nursing facility) 4. Coordination with home- and community-based providers of clinical services

My signature below indicates my understanding and agreement to receive CCM services and that I understand: 1. Dr Osuji, MD is designated by me for purposes of providing CCM to me and for submitting claims for payment to Medicare for the CCM services 2. I will receive a copy of my comprehensive plan of care 3. Dr Osuji, MD is authorized to electronically communicate my medical infromation with other treating providers as part of the care coordination involved in CCM services 4. Medicare will only pay one prfessional/ practice for CCM services provided t me during a calendar month, 5. CCM services are subject to the usual Medicare deductible and coinsurance applied to my Medicare Part B services, and 6. I can revoke this agreement at any time (effective at the end of the current calendar month) and can choose to receive these services at all after the calender month in which I revoke this agreement.

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