If consenting as the patients Legal Representative, please complete the following:
To be eligible for the program:
? I understand that I must have two chronic conditions lasting longer than 12 months.
? I have been seen by my referring provider within the last 12 months.
? I must have Medicare as my primary insurance or a Medicare Advantage plan.
? I cannot participate in two chronic care management services within a calendar month.
? I understand I have the right to opt out the program at any time, but I must inform a HealthWatch representative of my request.
? It is my responsibility to provide my referring provider with up-to-date insurance information for billing purposes.
? I understand that some secondary insurances may not cover the program or require a possible copay for any provided services.
? I will contact my insurance with any questions regarding coverage of services.
By checking the above box, you are verifying you've read, understand, and agree to all conditions indicated on this consent form.
