THANK YOU FOR YOUR INTEREST IN OUR CONNECTED CARE MANAGEMENT PROGRAM.

I hereby authorize my provider to enroll me in their Connected Care Management Program which allows their care coordinators to communicate with me about my medical conditions and treatment using phone calls, text messages, and/or email. This medical benefit is called Chronic Care Management (CCM) and is covered by Medicare and typically most other private insurance providers. The goal of the program is to provide ongoing, uninterrupted care for my medical conditions when I am away from the medical practice. I may unenroll from this service at any time and for any reason in the future.

Patient Cell Phone:
(required for participation)