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CONSENT AGREEMENT FOR THE PROVISION OF CHRONIC CARE MANAGEMENT (CCM) SERVICES By signing this Agreement, you consent to have the named provider below, or any other designated clinician at Resurge
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How to fill out consent for chronic care

01
Begin by reviewing the consent form to familiarize yourself with the information required.
02
Write the date at the top of the form.
03
Fill in your personal information, including your full name, date of birth, address, and contact information.
04
Provide details of your primary healthcare provider, including their name, contact information, and any relevant medical record numbers.
05
Read through the consent for chronic care carefully and make sure you understand all the terms and conditions.
06
Sign and date the form at the designated spaces.
07
If applicable, include the name and contact information of a person who can act as your healthcare proxy.
08
Return the completed consent form to the relevant healthcare provider.

Who needs consent for chronic care?

01
Anyone receiving chronic care treatments, such as long-term medication management, ongoing therapy, or disease-specific care, may need to fill out a consent form for chronic care. This includes individuals with chronic health conditions or those who require regular healthcare services to manage their ongoing medical needs.
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Consent for chronic care is a form that allows healthcare providers to treat and manage a patient's chronic health condition.
Consent for chronic care needs to be filed by the patient or their legal guardian.
Consent for chronic care can be filled out by providing personal information, medical history, contact information, and signing the form.
The purpose of consent for chronic care is to ensure that healthcare providers have authorization to treat and manage a patient's chronic health condition.
Information such as personal details, medical history, emergency contacts, and treatment preferences must be reported on consent for chronic care.
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